Basic Information
| Provider Information | |||||||||
| NPI: | 1366485179 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACNAUGHTON | ||||||||
| FirstName: | JON | ||||||||
| MiddleName: | MARK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MACNAUGHTON | ||||||||
| OtherFirstName: | J. | ||||||||
| OtherMiddleName: | MARK | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6077 PRIMACY PKWY STE 140 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381195742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017258347 | ||||||||
| FaxNumber: | 9012597637 | ||||||||
| Practice Location | |||||||||
| Address1: | 6029 WALNUT GROVE RD STE 403 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381202112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012617836 | ||||||||
| FaxNumber: | 9012260215 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 12/29/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | MD023561 | TN | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0005X | 23561 | TN | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | Q004845 | 05 | TN | MEDICAID | 3373632 | 01 | TN | MEDICARE GROUP PTAN | OTHER | 6186158 | 01 | TN | BCBS | OTHER | 3069679 | 05 | TN | MEDICAID | 4232034 | 01 | TN | BLUE CROSS BLUE SHIELD OF TENNESSEE | OTHER | T07653B | 01 | TN | MEDICARE | OTHER |