MEDICARE: DR. JORDAN DANIEL FETT M.D

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	4301110615	MI
2	2080P0214X	Pediatric Pulmonology Physician	2022-02032	NC

General Provider Information

NPI Number	:	1336599273
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JORDAN DANIEL FETT M.D

Provider Business Mailing Address
First Line	:	100 KIMEL FOREST DR
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-6074
Country	:	US
Telephone Number	:	336-716-0238
Fax Number	:

Provider Business Practice Location Address
First Line	:	MEDICAL CENTER BLVD
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27157-0001
Country	:	US
Telephone Number	:	336-713-4500
Fax Number	:	336-713-4501

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

Provider Enumeration Date	:	06/21/2016
Last Update Date	:	03/02/2023

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