Provider Demographics
NPI:1164422655
Name:NICHOLSON, BRENDA PITTMAN (MD)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:PITTMAN
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10988
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37939-0988
Mailing Address - Country:US
Mailing Address - Phone:865-862-0998
Mailing Address - Fax:865-544-1861
Practice Address - Street 1:1415 OLD WEISGARBER RD
Practice Address - Street 2:SUTIE 200
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37909-1292
Practice Address - Country:US
Practice Address - Phone:865-934-5800
Practice Address - Fax:865-934-5801
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000026965207RH0003X
KY37952207RH0003X
NC9400654207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3823592Medicaid
KY64721392Medicaid
KYP400033941Medicare PIN
G67843Medicare UPIN
TN3823592Medicaid
TN3823592Medicare PIN