Provider Demographics
NPI:1285654111
Name:DIBRELL, FREDRICK S (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDRICK
Middle Name:S
Last Name:DIBRELL
Suffix:
Gender:M
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 11527
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37401-2527
Mailing Address - Country:US
Mailing Address - Phone:423-778-3274
Mailing Address - Fax:423-778-2255
Practice Address - Street 1:136 WHEELERTOWN AVENUE
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37367-5247
Practice Address - Country:US
Practice Address - Phone:423-447-3524
Practice Address - Fax:423-447-3621
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE1622207R00000X
TN45770207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR134513001Medicaid
TN1517996Medicaid
AR5K789OtherBLUE CROSS BLUE SHIELD
ARP0117339OtherRAILROAD MEDICARE
AR18437000000OtherQUALCHOICE
AR18437000000OtherQUALCHOICE
AR5K789OtherBLUE CROSS BLUE SHIELD
ARP0117339OtherRAILROAD MEDICARE
ARG70099Medicare UPIN