Provider Demographics
NPI:1497807044
Name:SUMMERILL, SHAUN STEPHEN (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAUN
Middle Name:STEPHEN
Last Name:SUMMERILL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1151 HOSPITAL WAY
Mailing Address - Street 2:BLDG. F
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201
Mailing Address - Country:US
Mailing Address - Phone:208-232-1443
Mailing Address - Fax:208-239-3434
Practice Address - Street 1:1151 HOSPITAL WAY
Practice Address - Street 2:BLDG F
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-232-1443
Practice Address - Fax:208-239-3434
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2016-09-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI49001208000000X, 2080P0204X
IDM-11365208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808342900Medicaid