1477619872 NPI number — DR. MARK BRUMMEL D.O.

Table of content: DR. MARK BRUMMEL D.O. (NPI 1477619872)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477619872 NPI number — DR. MARK BRUMMEL D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRUMMEL
Provider First Name:
MARK
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1477619872
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/16/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 699
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNTAIN HOME
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37684-0699
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-433-6039
Provider Business Mailing Address Fax Number:
423-433-6060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
102 E RAVINE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KINGSPORT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37660-3814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-245-9600
Provider Business Practice Location Address Fax Number:
423-245-9634
Provider Enumeration Date:
12/29/2006

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:  DO1970 , 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: 1507939 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3714470 . This is a "GROUP MEDICARE PIN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".