Healthcare Provider Details

I. General information

NPI: 1912189085
Provider Name (Legal Business Name): PEDIATRICS TO PARENTS MEDICAL, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2007
Last Update Date: 08/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1442 N BROAD ST SUITE 7
TAZEWELL TN
37879-4361
US

IV. Provider business mailing address

PO BOX 959
NEW TAZEWELL TN
37824-0959
US

V. Phone/Fax

Practice location:
  • Phone: 423-626-1931
  • Fax:
Mailing address:
  • Phone: 423-626-1931
  • Fax: 423-626-1948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number000999
License Number StateTN

VIII. Authorized Official

Name: DR. RONALD JC FEJERAN
Title or Position: PRESIDENT AND PHYSICIAN
Credential: DO
Phone: 423-626-1931