Basic Information
| Provider Information | |||||||||
| NPI: | 1205942547 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUMARLIDASON | ||||||||
| FirstName: | ROXANNA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | B.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2550 REEVES ST | ||||||||
| Address2: | |||||||||
| City: | HOKES BLUFF | ||||||||
| State: | AL | ||||||||
| PostalCode: | 359037349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2564940757 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2409 HOMER CLAYTON DR | ||||||||
| Address2: | |||||||||
| City: | GUNTERSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 359762207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2565823203 | ||||||||
| FaxNumber: | 2565823216 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 51525325 | 01 | AL | BCBS | OTHER |