Basic Information
| Provider Information | |||||||||
| NPI: | 1285654111 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIBRELL | ||||||||
| FirstName: | FREDRICK | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11527 | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374012527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237783274 | ||||||||
| FaxNumber: | 4237782255 | ||||||||
| Practice Location | |||||||||
| Address1: | 136 WHEELERTOWN AVENUE | ||||||||
| Address2: | |||||||||
| City: | PIKEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373675247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234473524 | ||||||||
| FaxNumber: | 4234473621 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 10/27/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | E1622 | AR | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 45770 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 45770 | TN | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 134513001 | 05 | AR | MEDICAID | 1517996 | 05 | TN | MEDICAID | 5K789 | 01 | AR | BLUE CROSS BLUE SHIELD | OTHER | P0117339 | 01 | AR | RAILROAD MEDICARE | OTHER | 18437000000 | 01 | AR | QUALCHOICE | OTHER |