MEDICARE: PAUL J FETTERLY MD, FACOG

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	207Q00000X	Family Medicine Physician	7419	ND

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	:	1801895610
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAUL J FETTERLY MD, FACOG

Provider Business Mailing Address
First Line	:	PO BOX 1100
Second Line	:
City	:	DEVILS LAKE
State	:	ND
Zip	:	58301-1100
Country	:	US
Telephone Number	:	701-662-2157
Fax Number	:	701-662-4116

Provider Business Practice Location Address
First Line	:	1001 7TH ST NE
Second Line	:
City	:	DEVILS LAKE
State	:	ND
Zip	:	58301-2719
Country	:	US
Telephone Number	:	701-662-2157
Fax Number	:	701-662-4116

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

Provider Enumeration Date	:	07/14/2005
Last Update Date	:	03/21/2014

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