Provider Demographics
NPI:1801842570
Name:COTTRELL, BEN EDGAR (MD)
Entity Type:Individual
Prefix:
First Name:BEN
Middle Name:EDGAR
Last Name:COTTRELL
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 1:705 BLACK CREEK DR
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37419-2190
Mailing Address - Country:US
Mailing Address - Phone:931-588-6356
Mailing Address - Fax:
Practice Address - Street 1:705 BLACK CREEK DR
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37419-2190
Practice Address - Country:US
Practice Address - Phone:931-588-6356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN35175208M00000X, 207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3862460Medicaid
TNTN0109OtherAMERICHOICE
TN3862466Medicaid
TN4144771OtherBLUE CROSS
TN3862460Medicaid
TNH11824Medicare UPIN
TN3862466Medicaid