Provider Demographics
NPI:1639206212
Name:SUMMIT MEDICAL GROUP, PLLC
Entity Type:Organization
Organization Name:SUMMIT MEDICAL GROUP, PLLC
Other - Org Name:TRINITY MEDICAL ASSOCIATES, PC NON-PHARMACY DISPENSING SITE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:ZANDRA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MILLS
Authorized Official - Suffix:
Authorized Official - Credentials:BSOM, CPCS
Authorized Official - Phone:865-500-2144
Mailing Address - Street 1:1275 DICK LONAS RD UNIT 101
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-1383
Mailing Address - Country:US
Mailing Address - Phone:865-500-2144
Mailing Address - Fax:865-381-1509
Practice Address - Street 1:280 FORT SANDERS WEST BLVD STE 101
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-3352
Practice Address - Country:US
Practice Address - Phone:865-934-4252
Practice Address - Fax:865-539-1816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN20447332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
4440119OtherNCPDP PROVIDER IDENTIFICATION NUMBER