Provider Demographics
NPI:1508930843
Name:FRETWELL, BRIAN T (PAC MPH)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:T
Last Name:FRETWELL
Suffix:
Gender:M
Credentials:PAC MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 HUNTERS RUN TRL NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-6205
Mailing Address - Country:US
Mailing Address - Phone:423-650-2987
Mailing Address - Fax:
Practice Address - Street 1:2121 N OCOEE ST
Practice Address - Street 2:SUITE 101
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311-3953
Practice Address - Country:US
Practice Address - Phone:423-472-6548
Practice Address - Fax:423-472-8318
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1070207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2000307OtherBCBS OF TN
TNTN0101OtherJOHN DEERE
TN0140208OtherUNITED HEALTHCARE
TN3662424Medicaid
TNFP62706OtherWORKERS COMP
TNFP62706OtherWORKERS COMP
TN3719099Medicare PIN
TNTN0101OtherJOHN DEERE