=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568627271
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUMMIT CONVENIENT CARE AT LEBANON LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2008
-----------------------------------------------------
Last Update Date | 05/20/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 PHYSICIANS WAY SUITE 110
-----------------------------------------------------
City | LEBANON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37090-8102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-449-1100
-----------------------------------------------------
Fax | 615-449-1150
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 PHYSICIANS WAY SUITE 110
-----------------------------------------------------
City | LEBANON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37090-8102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-449-1100
-----------------------------------------------------
Fax | 615-449-1150
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | GARY DUNCAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-372-5135
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------