Basic Information
| Provider Information | |||||||||
| NPI: | 1043373152 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUMMIT PAIN SPECIALISTS INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4302 ALLEN RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | STOW | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442241032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3309459551 | ||||||||
| FaxNumber: | 3309459920 | ||||||||
| Practice Location | |||||||||
| Address1: | 4302 ALLEN RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | STOW | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442241032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3309459551 | ||||||||
| FaxNumber: | 3309459920 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2006 | ||||||||
| LastUpdateDate: | 06/02/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SPONSELLER | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGED CARE COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 3309459551 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2259532 | 05 | OH | MEDICAID |