Healthcare Provider Details

I. General information

NPI: 1104813138
Provider Name (Legal Business Name): PETER DONALD SERSHON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 BMH PHYSICIANS OFFICE BLDG
MARYVILLE TN
37804-5807
US

IV. Provider business mailing address

300 E MCBEE AVE FL 4
GREENVILLE SC
29601-2842
US

V. Phone/Fax

Practice location:
  • Phone: 865-980-5260
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number60706
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number33642
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: