Healthcare Provider Details

I. General information

NPI: 1548286206
Provider Name (Legal Business Name): JASON MATTHEW FISH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 PLEASANT ROW NW
HUNTSVILLE AL
35816-2537
US

IV. Provider business mailing address

PO BOX 18488
HUNTSVILLE AL
35804-8488
US

V. Phone/Fax

Practice location:
  • Phone: 256-533-6311
  • Fax: 256-536-0801
Mailing address:
  • Phone: 256-534-8659
  • Fax: 256-533-0276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101259223
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number010691498A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number19748
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: