Provider Demographics
NPI:1669828919
Name:SUMMER, MADELYN
Entity Type:Individual
Prefix:
First Name:MADELYN
Middle Name:
Last Name:SUMMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29022 GRATIOT AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-4112
Mailing Address - Country:US
Mailing Address - Phone:586-296-1230
Mailing Address - Fax:586-296-2676
Practice Address - Street 1:29022 GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4112
Practice Address - Country:US
Practice Address - Phone:586-296-1230
Practice Address - Fax:586-296-2676
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-05
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3501008005174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist