Provider Demographics
NPI:1891783981
Name:SUMMIT BONE & JOINT, PLLC
Entity Type:Organization
Organization Name:SUMMIT BONE & JOINT, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:LADOUCEUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-232-3838
Mailing Address - Street 1:P.O. BOX 306020
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37230-6020
Mailing Address - Country:US
Mailing Address - Phone:615-232-3838
Mailing Address - Fax:615-232-3833
Practice Address - Street 1:5653 FRIST BLVD
Practice Address - Street 2:SUITE 731
Practice Address - City:HERMITAGE
Practice Address - State:TN
Practice Address - Zip Code:37076
Practice Address - Country:US
Practice Address - Phone:615-232-3838
Practice Address - Fax:615-232-3833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-12
Last Update Date:2009-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000031901207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2638088OtherAETNA HMO
TN4023754OtherBCBS
TN1506501Medicaid
TN2000043639OtherRAILROAD MEDICARE
TN0940372OtherUNITED HEALTHCARE
TN0516031005OtherCIGNA HMO-POS
TN0516031006OtherCIGNA PPO
TN5282039OtherAETNA PPO
TN5282039OtherAETNA PPO
TN3375158Medicare ID - Type UnspecifiedGRP
TN4448860001Medicare NSC
TN2638088OtherAETNA HMO
TN4023754OtherBCBS