Healthcare Provider Details

I. General information

NPI: 1891719324
Provider Name (Legal Business Name): MICHAEL SUMMERS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 07/14/2025
Certification Date: 07/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12101 CAROL LN STE 101
FREDERICKSBURG VA
22407-6104
US

IV. Provider business mailing address

250 N SHADELAND AVE STE 130
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 540-741-9300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number0101273522
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01034573A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101273522
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: