MEDICARE: DR. RONALD JC FEJERAN DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	999	TN
2	207R00000X	Internal Medicine Physician	D0999	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073518288
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RONALD JC FEJERAN DO

Provider Business Mailing Address
First Line	:	PO BOX 959
Second Line	:	ATTN: CREDENTIALING
City	:	NEW TAZEWELL
State	:	TN
Zip	:	37824-0959
Country	:	US
Telephone Number	:	423-626-1931
Fax Number	:

Provider Business Practice Location Address
First Line	:	1442 N BROAD ST
Second Line	:	SUITE 7
City	:	TAZEWELL
State	:	TN
Zip	:	37879-4361
Country	:	US
Telephone Number	:	423-626-1931
Fax Number	:	423-626-1948

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2005
Last Update Date	:	01/07/2020

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