Basic Information
| Provider Information | |||||||||
| NPI: | 1629117890 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FISH | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | ROSS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1233 34TH ST NW | ||||||||
| Address2: | |||||||||
| City: | BEMIDJI | ||||||||
| State: | MN | ||||||||
| PostalCode: | 566015112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183335283 | ||||||||
| FaxNumber: | 2183335360 | ||||||||
| Practice Location | |||||||||
| Address1: | 1233 34TH ST NW | ||||||||
| Address2: | |||||||||
| City: | BEMIDJI | ||||||||
| State: | MN | ||||||||
| PostalCode: | 566015112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183335283 | ||||||||
| FaxNumber: | 2183335360 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2007 | ||||||||
| LastUpdateDate: | 03/29/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 24357 | OK | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 11109 | ND | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 46718 | MN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 10732 | 05 | ND | MEDICAID |