=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912189085
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDIATRICS TO PARENTS MEDICAL, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2007
-----------------------------------------------------
Last Update Date | 08/12/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1442 N BROAD ST SUITE 7
-----------------------------------------------------
City | TAZEWELL
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37879-4361
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-626-1931
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 959
-----------------------------------------------------
City | NEW TAZEWELL
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37824-0959
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-626-1931
-----------------------------------------------------
Fax | 423-626-1948
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT AND PHYSICIAN
-----------------------------------------------------
Name | DR. RONALD JC FEJERAN
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 423-626-1931
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number | 000999
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------