=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821069196
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TYRE K JONES IV
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2006
-----------------------------------------------------
Last Update Date | 05/29/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1579 WEDGEWOOD PL
-----------------------------------------------------
City | ESSEXVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48732
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-891-0598
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1579 WEDGEWOOD PL
-----------------------------------------------------
City | ESSEXVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48732-3203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-891-0598
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 4301061400
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------