Provider Demographics
NPI:1497751671
Name:SUMMERS, SHANE O (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:O
Last Name:SUMMERS
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 1:221 13TH AVENUE PL NW
Mailing Address - Street 2:STE 202
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28601-2596
Mailing Address - Country:US
Mailing Address - Phone:828-322-8484
Mailing Address - Fax:828-324-9526
Practice Address - Street 1:221 13TH AVENUE PL NW
Practice Address - Street 2:STE 202
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28601-2596
Practice Address - Country:US
Practice Address - Phone:828-322-8484
Practice Address - Fax:828-324-9526
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9401061207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7980873Medicaid
NC7980873Medicaid
NCF90558Medicare UPIN