Provider Demographics
NPI:1982604120
Name:SUMMERVILLE, JOHN WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WILLIAM
Last Name:SUMMERVILLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5301 VIRGINIA WAY STE 300
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7542
Mailing Address - Country:US
Mailing Address - Phone:615-221-4400
Mailing Address - Fax:
Practice Address - Street 1:200 MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805
Practice Address - Country:US
Practice Address - Phone:615-221-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101041829207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006603858Medicaid
30085OtherOPTIMAHEALTH
VA006603858Medicaid
220025029OtherRAILROAD MEDICARE
220025029OtherRAILROAD MEDICARE
VA006603858Medicaid