Provider Demographics
NPI:1326170473
Name:BRUNVOLL, TERRI R (DO)
Entity Type:Individual
Prefix:DR
First Name:TERRI
Middle Name:R
Last Name:BRUNVOLL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 EXECUTIVE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-7916
Mailing Address - Country:US
Mailing Address - Phone:423-870-2030
Mailing Address - Fax:423-875-6405
Practice Address - Street 1:1025 EXECUTIVE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-7916
Practice Address - Country:US
Practice Address - Phone:423-870-2030
Practice Address - Fax:423-875-6405
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN207Q00000X207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5064580Medicaid
TN080157953OtherMEDICARE RR
TNDO0000001148OtherMEDICAL LICENSE
TNF51312Medicare UPIN
TN3720420Medicare PIN
TN5064580Medicaid