Basic Information
| Provider Information | |||||||||
| NPI: | 1841403243 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JONESBOROUGH MEDICAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1003 E JACKSON BLVD | ||||||||
| Address2: | |||||||||
| City: | JONESBOROUGH | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376591538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237536077 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1003 E JACKSON BLVD | ||||||||
| Address2: | |||||||||
| City: | JONESBOROUGH | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376591538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237536077 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | NASERI | ||||||||
| AuthorizedOfficialFirstName: | MOUSA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4237536077 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 305R00000X | APN6456 | TN | Y | Managed Care Organizations | Preferred Provider Organization |
No ID Information.