Provider Demographics
NPI:1629117890
Name:FISH, JONATHAN ROSS (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ROSS
Last Name:FISH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1233 34TH ST NW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-5112
Mailing Address - Country:US
Mailing Address - Phone:218-333-5283
Mailing Address - Fax:218-333-5360
Practice Address - Street 1:1233 34TH ST NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-5112
Practice Address - Country:US
Practice Address - Phone:218-333-5283
Practice Address - Fax:218-333-5360
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK243572085R0202X
ND111092085R0202X
MN467182085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND10732Medicaid
MN300005228Medicare PIN
NDN716674Medicare PIN