Provider Demographics
NPI:1497751960
Name:FETH, MARY H
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:H
Last Name:FETH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-2634
Mailing Address - Country:US
Mailing Address - Phone:636-432-1560
Mailing Address - Fax:636-432-1563
Practice Address - Street 1:320 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-2634
Practice Address - Country:US
Practice Address - Phone:636-432-1560
Practice Address - Fax:636-432-1563
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-21
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMD106702208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207801309Medicaid
MO207801309Medicaid