Provider Demographics
NPI:1568627271
Name:SUMMIT CONVENIENT CARE AT LEBANON LLC
Entity Type:Organization
Organization Name:SUMMIT CONVENIENT CARE AT LEBANON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNCAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-372-5135
Mailing Address - Street 1:100 PHYSICIANS WAY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37090-8102
Mailing Address - Country:US
Mailing Address - Phone:615-449-1100
Mailing Address - Fax:615-449-1150
Practice Address - Street 1:100 PHYSICIANS WAY
Practice Address - Street 2:SUITE 110
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37090-8102
Practice Address - Country:US
Practice Address - Phone:615-449-1100
Practice Address - Fax:615-449-1150
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOSPITAL CORP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-22
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1511412Medicaid
TN4214465OtherBCBS
TNDO3658OtherRR MEDICARE
TNDO3658OtherRR MEDICARE