Basic Information
| Provider Information | |||||||||
| NPI: | 1083736128 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUMMIT HEALTHCARE ASSOCIATION | ||||||||
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| OtherOrganizationName: | SUMMIT HEALTHCARE ONCOLOGY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 E HUNT ST | ||||||||
| Address2: | SUITE H | ||||||||
| City: | SHOW LOW | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859017954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285376937 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2500 E HUNT ST | ||||||||
| Address2: | SUITE H | ||||||||
| City: | SHOW LOW | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859017954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285376937 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2007 | ||||||||
| LastUpdateDate: | 07/31/2008 | ||||||||
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| AuthorizedOfficialLastName: | ALLEN | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | ROBERT | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 9285376399 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUMMIT HEALTHCARE ASSOCIATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QX0203X | 3376 | AZ | N | Ambulatory Health Care Facilities | Clinic/Center | Oncology, Radiation | 261QX0200X | 3376 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Oncology |
ID Information
| ID | Type | State | Issuer | Description | 020016 | 05 | AZ | MEDICAID |