Basic Information
| Provider Information | |||||||||
| NPI: | 1891418232 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUMMIT MEDICAL GROUP,PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1275 DICK LONAS RD UNIT 101 | ||||||||
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| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379091383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655002144 | ||||||||
| FaxNumber: | 8655841363 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 GRADY RD | ||||||||
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| City: | ETOWAH | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373311924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232631743 | ||||||||
| FaxNumber: | 4232637723 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2022 | ||||||||
| LastUpdateDate: | 09/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | MILLS | ||||||||
| AuthorizedOfficialFirstName: | ZANDRA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8655002144 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUMMIT MEDICAL GROUP,PLLC | ||||||||
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| AuthorizedOfficialCredential: | BSOM, CPCS | ||||||||
| NPICertificationDate: | 09/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.