Healthcare Provider Details

I. General information

NPI: 1285654111
Provider Name (Legal Business Name): FREDRICK S DIBRELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 10/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 WHEELERTOWN AVENUE
PIKEVILLE TN
37367-5247
US

IV. Provider business mailing address

PO BOX 11527
CHATTANOOGA TN
37401-2527
US

V. Phone/Fax

Practice location:
  • Phone: 423-447-3524
  • Fax: 423-447-3621
Mailing address:
  • Phone: 423-778-3274
  • Fax: 423-778-2255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberE1622
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number45770
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number45770
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: