Provider Demographics
NPI:1154323749
Name:FICHTEL, JILL C (MD)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:C
Last Name:FICHTEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:
Other - Last Name:CROWELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1909 MALLORY LN STE 302
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-2843
Mailing Address - Country:US
Mailing Address - Phone:615-905-4994
Mailing Address - Fax:615-224-6950
Practice Address - Street 1:1909 MALLORY LN STE 302
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37067-2843
Practice Address - Country:US
Practice Address - Phone:615-905-4994
Practice Address - Fax:615-224-6950
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.122022207N00000X
TNMD39348207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000928222OtherANTHEM BLUE CROSS & BLUE SHIELD
TN1508645Medicaid
TN33352641Medicare PIN
OH000000928222OtherANTHEM BLUE CROSS & BLUE SHIELD
TNI44853Medicare UPIN