1568442689 NPI number — MR. JONATHAN M KERLEY DO

Table of content: MR. JONATHAN M KERLEY DO (NPI 1568442689)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568442689 NPI number — MR. JONATHAN M KERLEY DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KERLEY
Provider First Name:
JONATHAN
Provider Middle Name:
M
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568442689
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/27/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7000 LEE HWY
Provider Second Line Business Mailing Address:
SUITE 600
Provider Business Mailing Address City Name:
CHATTANOOGA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37421-1799
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-894-0432
Provider Business Mailing Address Fax Number:
423-894-0475

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2372 LIFESTYLE WAY STE 152
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHATTANOOGA
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37421-4940
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-894-0432
Provider Business Practice Location Address Fax Number:
423-894-0475
Provider Enumeration Date:
01/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  2007029189 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 1427 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3307028 . This is a "MEDICARE PTAN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3370172 . This is a "MEDICARE PTAN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3307024 . This is a "MEDICARE PTAN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3726561 . This is a "MEDICARE PTAN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3307024 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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