Provider Demographics
NPI:1366686503
Name:SUMMERLIN, ADAM LEE (MD)
Entity Type:Individual
Prefix:MR
First Name:ADAM
Middle Name:LEE
Last Name:SUMMERLIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11955
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38308-0132
Mailing Address - Country:US
Mailing Address - Phone:888-630-0845
Mailing Address - Fax:
Practice Address - Street 1:620 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3923
Practice Address - Country:US
Practice Address - Phone:731-541-6174
Practice Address - Fax:731-541-8008
Is Sole Proprietor?:No
Enumeration Date:2009-04-30
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN525822085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ014176Medicaid
TNQ014176Medicaid