1639206212 NPI number — SUMMIT MEDICAL GROUP, PLLC

Table of content: (NPI 1639206212)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639206212 NPI number — SUMMIT MEDICAL GROUP, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUMMIT MEDICAL GROUP, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1639206212
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1275 DICK LONAS RD UNIT 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KNOXVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37909-1383
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-500-2144
Provider Business Mailing Address Fax Number:
865-381-1509

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
280 FORT SANDERS WEST BLVD STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KNOXVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37922-3352
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-934-4252
Provider Business Practice Location Address Fax Number:
865-539-1816
Provider Enumeration Date:
02/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MILLS
Authorized Official First Name:
ZANDRA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CREDENTIALING COORDINATOR
Authorized Official Telephone Number:
865-500-2144

Provider Taxonomy Codes

  • Taxonomy code: 332900000X , with the licence number:  20447 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4440119 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com