Provider Demographics
NPI:1740225887
Name:SUMMIT PRIMARY CARE
Entity Type:Organization
Organization Name:SUMMIT PRIMARY CARE
Other - Org Name:ROBERT B GASTON JR MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:DUGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-391-1515
Mailing Address - Street 1:3939 CENTRAL PIKE
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:TN
Mailing Address - Zip Code:37076-3410
Mailing Address - Country:US
Mailing Address - Phone:615-883-2331
Mailing Address - Fax:615-391-1785
Practice Address - Street 1:3939 CENTRAL PIKE
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:TN
Practice Address - Zip Code:37076-3410
Practice Address - Country:US
Practice Address - Phone:615-883-2331
Practice Address - Fax:615-391-1785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD10309332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3176920Medicaid
4439370OtherOTHER ID NUMBER-COMMERCIAL NUMBER
TN3176920Medicaid