Healthcare Provider Details

I. General information

NPI: 1629117890
Provider Name (Legal Business Name): JONATHAN ROSS FISH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 03/29/2022
Certification Date: 03/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1233 34TH ST NW
BEMIDJI MN
56601-5112
US

IV. Provider business mailing address

1233 34TH ST NW
BEMIDJI MN
56601-5112
US

V. Phone/Fax

Practice location:
  • Phone: 218-333-5283
  • Fax: 218-333-5360
Mailing address:
  • Phone: 218-333-5283
  • Fax: 218-333-5360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number24357
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number11109
License Number StateND
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number46718
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: