Basic Information
| Provider Information | |||||||||
| NPI: | 1104099662 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAVELLE | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 103 W BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378014703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652731752 | ||||||||
| FaxNumber: | 8652731755 | ||||||||
| Practice Location | |||||||||
| Address1: | 425 BMH PHYSICIANS OFFICE BLDG | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8659805260 | ||||||||
| FaxNumber: | 8659805261 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2008 | ||||||||
| LastUpdateDate: | 08/22/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | MD0000053291 | TN | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | Q019290 | 05 | TN | MEDICAID |