Provider Demographics
NPI:1083913776
Name:JONATHON PENDERGRASS, M.D.
Entity Type:Organization
Organization Name:JONATHON PENDERGRASS, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHON
Authorized Official - Middle Name:
Authorized Official - Last Name:PENDERGRASS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:251-631-3534
Mailing Address - Street 1:6801 AIRPORT BLVD
Mailing Address - Street 2:WCC/HBO
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36608-3709
Mailing Address - Country:US
Mailing Address - Phone:251-631-3534
Mailing Address - Fax:251-631-3531
Practice Address - Street 1:6801 AIRPORT BLVD
Practice Address - Street 2:WCC/HBO
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-3709
Practice Address - Country:US
Practice Address - Phone:251-631-3534
Practice Address - Fax:251-631-3531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-21
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL124572083P0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric MedicineGroup - Single Specialty