Basic Information
| Provider Information | |||||||||
| NPI: | 1982604120 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUMMERVILLE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5301 VIRGINIA WAY STE 300 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370277542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152214400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 MEDICAL PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | PETERSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152214400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2005 | ||||||||
| LastUpdateDate: | 06/10/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 0101041829 | VA | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 006603858 | 05 | VA | MEDICAID |