Healthcare Provider Details

I. General information

NPI: 1467204214
Provider Name (Legal Business Name): SUMMIT MEDICAL GROUP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2024
Last Update Date: 04/04/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1798 ROANE STATE HWY
HARRIMAN TN
37748-8305
US

IV. Provider business mailing address

1275 DICK LONAS RD
KNOXVILLE TN
37909-1382
US

V. Phone/Fax

Practice location:
  • Phone: 800-500-4667
  • Fax: 833-448-2981
Mailing address:
  • Phone: 865-584-4747
  • Fax: 865-381-1509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER RANEY
Title or Position: PROVIDER ENROLLMENT SUPERVISOR
Credential:
Phone: 865-269-2111