Basic Information
Provider Information | |||||||||
NPI: | 1407849649 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SERRELL | ||||||||
FirstName: | PAUL | ||||||||
MiddleName: | BURT | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6350 W ANDREW JOHNSON HWY | ||||||||
Address2: | DEPARTMENT 100 | ||||||||
City: | TALBOTT | ||||||||
State: | TN | ||||||||
PostalCode: | 378778605 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8003553565 | ||||||||
FaxNumber: | 4237142355 | ||||||||
Practice Location | |||||||||
Address1: | 2018 WESTERN AVE | ||||||||
Address2: |   | ||||||||
City: | KNOXVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 379215718 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8655440406 | ||||||||
FaxNumber: | 8655440480 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/23/2005 | ||||||||
LastUpdateDate: | 09/29/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/29/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | MD10143 | TN | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
ID | Type | State | Issuer | Description | 3149814 | 01 | TN | BLUE CROSS/BLUE SHIELD | OTHER | 390007315 | 01 | TN | RAILROAD MEDICARE | OTHER | 3723987 | 05 | TN |   | MEDICAID |