Healthcare Provider Details

I. General information

NPI: 1497748883
Provider Name (Legal Business Name): JONATHAN SCOTT FISH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 11/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2470 LONGSTONE LN STE I
MARRIOTTSVILLE MD
21104-1523
US

IV. Provider business mailing address

2470 LONGSTONE LN STE I
MARRIOTTSVILLE MD
21104-1523
US

V. Phone/Fax

Practice location:
  • Phone: 410-910-2300
  • Fax: 410-740-9134
Mailing address:
  • Phone: 410-910-2300
  • Fax: 410-910-2310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD0051860
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: