1508930843 NPI number — MR. BRIAN T FRETWELL PAC MPH

Table of content: MR. BRIAN T FRETWELL PAC MPH (NPI 1508930843)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508930843 NPI number — MR. BRIAN T FRETWELL PAC MPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FRETWELL
Provider First Name:
BRIAN
Provider Middle Name:
T
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PAC MPH
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508930843
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/20/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
149 HUNTERS RUN TRL NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37312-6205
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-650-2987
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2121 N OCOEE ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37311-3953
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-472-6548
Provider Business Practice Location Address Fax Number:
423-472-8318
Provider Enumeration Date:
11/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  1070 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2000307 . This is a "BCBS OF TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: TN0101 . This is a "JOHN DEERE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 0140208 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3662424 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: FP62706 . This is a "WORKERS COMP" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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