MEDICARE: PEDIATRICS TO PARENTS MEDICAL, PC

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	261QM1300X	Multi-Specialty Clinic/Center	000999	TN

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	:	1912189085
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRICS TO PARENTS MEDICAL, PC

Provider Business Mailing Address
First Line	:	PO BOX 959
Second Line	:
City	:	NEW TAZEWELL
State	:	TN
Zip	:	37824-0959
Country	:	US
Telephone Number	:	423-626-1931
Fax Number	:	423-626-1948

Provider Business Practice Location Address
First Line	:	1442 N BROAD ST
Second Line	:	SUITE 7
City	:	TAZEWELL
State	:	TN
Zip	:	37879-4361
Country	:	US
Telephone Number	:	423-626-1931
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT AND PHYSICIAN
Name	:	DR. RONALD JC FEJERAN
Credential	:	DO
Telephone Number	:	423-626-1931

Provider Enumeration Date	:	11/30/2007
Last Update Date	:	08/12/2008

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