1659606622 NPI number — DR. THOMAS FISHBURNE JEMISON N.M.D

Table of content: DR. THOMAS FISHBURNE JEMISON N.M.D (NPI 1659606622)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659606622 NPI number — DR. THOMAS FISHBURNE JEMISON N.M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JEMISON
Provider First Name:
THOMAS
Provider Middle Name:
FISHBURNE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
N.M.D
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:
1659606622
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/12/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1830 E BROADWAY BLVD STE 124-212
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85719-5966
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-420-3254
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2905 E BROADWAY BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85716-5311
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-331-8809
Provider Business Practice Location Address Fax Number:
480-420-3254
Provider Enumeration Date:
10/08/2009

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: 175F00000X , with the licence number:  09-1149 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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