Basic Information
| Provider Information | |||||||||
| NPI: | 1932213378 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FETTER HEALTH CARE NETWORK, INC | ||||||||
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| OtherOrganizationName: | FRANKLIN C FETTER PEDIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 51 NASSAU STREET | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294035513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437224112 | ||||||||
| FaxNumber: | 8435778960 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 EXECUTIVE PKWY | ||||||||
| Address2: | |||||||||
| City: | MONCKS CORNER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294613930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437617744 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2006 | ||||||||
| LastUpdateDate: | 04/15/2015 | ||||||||
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| AuthorizedOfficialLastName: | PETTIFORD | ||||||||
| AuthorizedOfficialFirstName: | REUBEN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8437224112 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | FQC049 | 05 | SC | MEDICAID |