=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235937764
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUMMIT MEDICAL GROUP PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2025
-----------------------------------------------------
Last Update Date | 03/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 629 MIDDLE CREEK RD
-----------------------------------------------------
City | SEVIERVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37862-5014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-453-9980
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1275 DICK LONAS RD UNIT 101
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37909-1383
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-584-4747
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROVIDER ENROLLMENT COORDINATOR
-----------------------------------------------------
Name | SANDRA DEE BOWLES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 865-584-4747
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------