Healthcare Provider Details

I. General information

NPI: 1699881052
Provider Name (Legal Business Name): BRUCE L FETTERMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 12/17/2020
Certification Date: 12/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7600 WOLF RIVER BLVD SUITE 220
GERMANTOWN TN
38138-1785
US

IV. Provider business mailing address

PO BOX 2757
CORDOVA TN
38088-2757
US

V. Phone/Fax

Practice location:
  • Phone: 901-755-5300
  • Fax: 901-756-0196
Mailing address:
  • Phone: 901-755-5300
  • Fax: 901-753-9659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License NumberMD29959
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: