Healthcare Provider Details

I. General information

NPI: 1093316184
Provider Name (Legal Business Name): TAYLOR MACKENZIE SUMMERS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2020
Last Update Date: 11/04/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 BROOKS ST STE 200
CHARLESTON WV
25301-1848
US

IV. Provider business mailing address

111 SUMMIT DR
MOREHEAD KY
40351-9706
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-1930
  • Fax:
Mailing address:
  • Phone: 606-207-4872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number2931
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: