=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316128580
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUMMIT FAMILY MEDICINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2007
-----------------------------------------------------
Last Update Date | 11/16/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 515 W SALISBURY ST SUITE D
-----------------------------------------------------
City | ASHEBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27203-5497
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-636-5100
-----------------------------------------------------
Fax | 336-636-5144
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 5086
-----------------------------------------------------
City | ASHEBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27204-5086
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-636-5100
-----------------------------------------------------
Fax | 336-636-5144
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | PAMELA A PENNER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 336-636-5100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 200101484
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------