Provider Demographics
NPI:1083996599
Name:SUMMERVILLE, ANITA CHAKRAPANI (PA-C)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:CHAKRAPANI
Last Name:SUMMERVILLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:937 N OPDYKE RD
Mailing Address - Street 2:
Mailing Address - City:AUBURN HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48326-2641
Mailing Address - Country:US
Mailing Address - Phone:248-373-7600
Mailing Address - Fax:248-373-7443
Practice Address - Street 1:5701 BOW POINTE DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-3199
Practice Address - Country:US
Practice Address - Phone:248-625-2621
Practice Address - Fax:248-625-2622
Is Sole Proprietor?:No
Enumeration Date:2011-09-12
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006134363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4989356Medicare PIN
0M39080070Medicare PIN
MI3292022Medicare PIN