Provider Demographics
NPI:1578547758
Name:LIDDELL, NORMAN E (MD, PHD)
Entity Type:Individual
Prefix:
First Name:NORMAN
Middle Name:E
Last Name:LIDDELL
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 FOX MEADOWS BOULEVARD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:SEVIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37862-6928
Mailing Address - Country:US
Mailing Address - Phone:865-428-4042
Mailing Address - Fax:865-428-8191
Practice Address - Street 1:1240 FOX MEADOWS BOULEVARD
Practice Address - Street 2:SUITE 6
Practice Address - City:SEVIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37862-6928
Practice Address - Country:US
Practice Address - Phone:865-428-4042
Practice Address - Fax:865-428-8191
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-01
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD28522174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN702002822OtherCARITEN
TN4024131OtherBCBS
TN10012098OtherPHP TENNCARE
TN8710353OtherCIGNA
TN4472010OtherAETNA
TN1578547758OtherHUMANA
TN38043801Medicaid
TN3940202OtherUNITED HEALTHCARE
TN38043801Medicare PIN
TN702002822OtherCARITEN