Basic Information
| Provider Information | |||||||||
| NPI: | 1609832690 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ISOM | ||||||||
| FirstName: | JOHNATHAN | ||||||||
| MiddleName: | MILTON | ||||||||
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| Credential: | MD, MBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 400 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383020400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7314255752 | ||||||||
| FaxNumber: | 7314225743 | ||||||||
| Practice Location | |||||||||
| Address1: | 5744 NANJACK CIR | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381152061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017979711 | ||||||||
| FaxNumber: | 9017979771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 12/20/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 20634 | TN | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 3030932 | 01 | TN | BCBS | OTHER | 302I059810 | 01 | MS | MEDICARE PTAN | OTHER |