Healthcare Provider Details

I. General information

NPI: 1669461679
Provider Name (Legal Business Name): DANIEL DAVID SUMROK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 03/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1894 CEDAR ST 1301 PRIMACY PARKWAY
MC KENZIE TN
38201-2206
US

IV. Provider business mailing address

1894 CEDAR ST
MC KENZIE TN
38201-2206
US

V. Phone/Fax

Practice location:
  • Phone: 731-352-0603
  • Fax: 731-352-0185
Mailing address:
  • Phone: 731-352-0603
  • Fax: 731-352-0185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number21860
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD0000021860
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: