MEDICARE: FETTER HEALTH CARE NETWORK, INC

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	261QF0400X	Federally Qualified Health Center (FQHC)
2	208000000X	Pediatrics Physician

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	:	1932213378
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FETTER HEALTH CARE NETWORK, INC

Provider Business Mailing Address
First Line	:	51 NASSAU STREET
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29403-5513
Country	:	US
Telephone Number	:	843-722-4112
Fax Number	:	843-577-8960

Provider Business Practice Location Address
First Line	:	110 EXECUTIVE PKWY
Second Line	:
City	:	MONCKS CORNER
State	:	SC
Zip	:	29461-3930
Country	:	US
Telephone Number	:	843-761-7744
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. REUBEN J PETTIFORD
Credential	:
Telephone Number	:	843-722-4112

Provider Enumeration Date	:	08/19/2006
Last Update Date	:	04/15/2015

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