Basic Information
| Provider Information | |||||||||
| NPI: | 1669031837 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUMMIT MEDICAL GROUP,PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PEDIATRIC CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1275 DICK LONAS RD UNIT 101 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379091383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655844747 | ||||||||
| FaxNumber: | 8655841363 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 HUXLEY RD | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379223197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655180084 | ||||||||
| FaxNumber: | 8655585669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2019 | ||||||||
| LastUpdateDate: | 07/09/2020 | ||||||||
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| AuthorizedOfficialLastName: | CURTIS | ||||||||
| AuthorizedOfficialFirstName: | ED | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8655844747 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUMMIT MEDICAL GROUP,PLLC | ||||||||
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| AuthorizedOfficialCredential: | CMPE | ||||||||
| NPICertificationDate: | 07/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | Q053040 | 05 | TN | MEDICAID |