Healthcare Provider Details

I. General information

NPI: 1790991545
Provider Name (Legal Business Name): ERIC J. FISH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 03/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL PK. BLVD.
BRISTOL TN
37620
US

IV. Provider business mailing address

3053 W. STATE ST.
BRISTOL TN
37620
US

V. Phone/Fax

Practice location:
  • Phone: 423-968-1144
  • Fax: 423-968-3453
Mailing address:
  • Phone: 423-968-1144
  • Fax: 423-968-3453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number5101016068
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: