Provider Demographics
NPI:1063586295
Name:SOMMERVILLE, LYNN HOLLEY (MD)
Entity type:Individual
Prefix:DR
First Name:LYNN
Middle Name:HOLLEY
Last Name:SOMMERVILLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:845 N MAIN ST
Mailing Address - Street 2:5
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-5700
Mailing Address - Country:US
Mailing Address - Phone:401-331-8338
Mailing Address - Fax:401-331-0573
Practice Address - Street 1:845 N MAIN ST
Practice Address - Street 2:STE 5
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-5700
Practice Address - Country:US
Practice Address - Phone:401-331-8338
Practice Address - Fax:401-331-0573
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2017-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD06858207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI0400917OtherUNITED HEALTHCARE
RI204125OtherBLUE CROSS BLUE SHIELD
RI902-04-12Medicaid
119020412Medicare ID - Type Unspecified
RI204125OtherBLUE CROSS BLUE SHIELD