1336167352 NPI number — SHERRY A SUMMITT R, MR

Table of content: SHERRY A SUMMITT R, MR (NPI 1336167352)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336167352 NPI number — SHERRY A SUMMITT R, MR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUMMITT
Provider First Name:
SHERRY
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
R, MR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336167352
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28 SPRINGHILL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENBRIER
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72058-9630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-679-0511
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2585 DONAGHEY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONWAY
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72032-2327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-764-1201
Provider Business Practice Location Address Fax Number:
501-764-1204
Provider Enumeration Date:
07/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 247100000X , with the licence number:  RTL000699 ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 2471M1202X , with the licence number: 191123 ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)





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