Basic Information
| Provider Information | |||||||||
| NPI: | 1568442689 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KERLEY | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7000 LEE HWY | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374211799 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238940432 | ||||||||
| FaxNumber: | 4238940475 | ||||||||
| Practice Location | |||||||||
| Address1: | 2372 LIFESTYLE WAY STE 152 | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374214940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238940432 | ||||||||
| FaxNumber: | 4238940475 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2006 | ||||||||
| LastUpdateDate: | 09/27/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 2007029189 | MO | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207R00000X | 1427 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3307028 | 01 | TN | MEDICARE PTAN | OTHER | 3370172 | 01 | TN | MEDICARE PTAN | OTHER | 3307024 | 01 | TN | MEDICARE PTAN | OTHER | 3726561 | 01 | TN | MEDICARE PTAN | OTHER | 3307024 | 05 | TN | MEDICAID |