Provider Demographics
NPI:1134363518
Name:FISHER, JEREMY GABRIEL (MD)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:GABRIEL
Last Name:FISHER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:979 E 3RD ST STE 300
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37403-2187
Mailing Address - Country:US
Mailing Address - Phone:423-267-0466
Mailing Address - Fax:423-778-5177
Practice Address - Street 1:979 E 3RD ST STE 300
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2187
Practice Address - Country:US
Practice Address - Phone:423-267-0466
Practice Address - Fax:423-778-5177
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-28
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.1287542086S0120X
TN615142086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0292539Medicaid
TNQ060604Medicaid
OHH635870OtherCGS-MEDICARE