Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2086S0120X | Pediatric Surgery | 35.128754 | OH |
Y | 2086S0120X | Pediatric Surgery | 61514 | TN |
NPI | 1134363518 |
---|---|
Provider Name | Jeremy Gabriel Fisher |
First Address | Chattanooga, TN 37403-2187 |
Second Address | Chattanooga, TN 37403-2187 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/04/2009 |
Last Update Date | 17/09/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0292539 | (05) | OH |
H635870 | CGS-MEDICARE (01) | OH |