Basic Information
| Provider Information | |||||||||
| NPI: | 1477619872 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRUMMEL | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 699 | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376840699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234336039 | ||||||||
| FaxNumber: | 4234336060 | ||||||||
| Practice Location | |||||||||
| Address1: | 102 E RAVINE RD | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376603814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232459600 | ||||||||
| FaxNumber: | 4232459634 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2006 | ||||||||
| LastUpdateDate: | 11/08/2016 | ||||||||
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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 | 207Q00000X | DO1970 | TN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3714470 | 01 | TN | GROUP MEDICARE PIN | OTHER | 1507939 | 05 | TN | MEDICAID |