MEDICARE: BRUCE SUMMERVILLE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207X00000X	Orthopaedic Surgery Physician	036-088414	IL

General Provider Information

NPI Number	:	1164474979
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRUCE SUMMERVILLE MD

Provider Business Mailing Address
First Line	:	900 RAND RD STE 300
Second Line	:	ATTN: RAQUEL LEON
City	:	DES PLAINES
State	:	IL
Zip	:	60016-2359
Country	:	US
Telephone Number	:	847-324-3976
Fax Number	:

Provider Business Practice Location Address
First Line	:	350 S GREENLEAF ST
Second Line	:	SUITE 405
City	:	GURNEE
State	:	IL
Zip	:	60031-5709
Country	:	US
Telephone Number	:	847-336-3335
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/17/2006
Last Update Date	:	12/20/2021

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