MEDICARE: MARY H FETH

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	MD106702	MO

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

General Provider Information

NPI Number	:	1497751960
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY H FETH

Provider Business Mailing Address
First Line	:	320 JEFFERSON ST
Second Line	:
City	:	WASHINGTON
State	:	MO
Zip	:	63090-2634
Country	:	US
Telephone Number	:	636-432-1560
Fax Number	:	636-432-1563

Provider Business Practice Location Address
First Line	:	320 JEFFERSON ST
Second Line	:
City	:	WASHINGTON
State	:	MO
Zip	:	63090-2634
Country	:	US
Telephone Number	:	636-432-1560
Fax Number	:	636-432-1563

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

Provider Enumeration Date	:	06/21/2005
Last Update Date	:	02/28/2013

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