1285654111 NPI number — DR. FREDRICK S DIBRELL M.D.

Table of content: DR. FREDRICK S DIBRELL M.D. (NPI 1285654111)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285654111 NPI number — DR. FREDRICK S DIBRELL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIBRELL
Provider First Name:
FREDRICK
Provider Middle Name:
S
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1285654111
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/27/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11527
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHATTANOOGA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37401-2527
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-778-3274
Provider Business Mailing Address Fax Number:
423-778-2255

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
136 WHEELERTOWN AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PIKEVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37367-5247
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-447-3524
Provider Business Practice Location Address Fax Number:
423-447-3621
Provider Enumeration Date:
07/21/2006

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: 207R00000X , with the licence number:  E1622 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 45770 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X , with the licence number: 45770 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 134513001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1517996 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5K789 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: P0117339 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 18437000000 . This is a "QUALCHOICE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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