Provider Demographics
NPI:1639158520
Name:SUMRALL, MICHELLE JACKSON (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:JACKSON
Last Name:SUMRALL
Suffix:
Gender:F
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 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6879
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:1301 RING RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-8968
Practice Address - Country:US
Practice Address - Phone:270-765-2107
Practice Address - Fax:270-169-9642
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY37097208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK182871OtherMEDICARE
KY000000225528OtherANTHEM
IN300052072Medicaid
KY64049216Medicaid
KY000000225528OtherANTHEM
KY012819OtherSIHO
KY0504002Medicare ID - Type Unspecified
KY64049216Medicaid