Basic Information
| Provider Information | |||||||||
| NPI: | 1134106032 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAMILY PRACTICE OF SUMMERFIELD PLLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DRS BURNETT KAPLAN & WILSON LLP | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 220 | ||||||||
| Address2: | |||||||||
| City: | SUMMERFIELD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273580220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366437711 | ||||||||
| FaxNumber: | 3366433047 | ||||||||
| Practice Location | |||||||||
| Address1: | 4431 HIGHWAY 220 NORTH | ||||||||
| Address2: | |||||||||
| City: | SUMMERFIELD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273589411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366437711 | ||||||||
| FaxNumber: | 3366433047 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2005 | ||||||||
| LastUpdateDate: | 04/28/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BURNETT | ||||||||
| AuthorizedOfficialFirstName: | BRENT | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 3366437711 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8901586 | 05 | NC | MEDICAID |