Provider Demographics
NPI:1700825940
Name:FRIDAY, JACK MICHAEL (MD)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:MICHAEL
Last Name:FRIDAY
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 1:3024 BUSINESS PARK CIR
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-3132
Mailing Address - Country:US
Mailing Address - Phone:615-851-6033
Mailing Address - Fax:615-851-2018
Practice Address - Street 1:3024 BUSINESS PARK CIR
Practice Address - Street 2:
Practice Address - City:GOODLETTSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37072-3132
Practice Address - Country:US
Practice Address - Phone:615-851-6033
Practice Address - Fax:615-851-2018
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD258002085R0202X
TN258002085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3031174OtherBCBS
TN4291356OtherBCBS - MTI
TN1509266OtherMEDICAID - MTI
TN300108653OtherRAILROAD MEDICARE
TN3083732Medicaid
TN3136571OtherBCBS
TN4200799OtherBCBS TN
KY64924590OtherKY MEDICAID
KY6492459000Medicaid
TN1509266Medicaid
KY6492459000Medicaid
TNF44380Medicare UPIN
TN300108653OtherRAILROAD MEDICARE
TN3083732Medicaid
TN3083736Medicare PIN