Basic Information
| Provider Information | |||||||||
| NPI: | 1164703476 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUMMIT PAIN SPECIALISTS, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SUMMIT PAIN SPECIALISTS PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4302 ALLEN RD STE 300 | ||||||||
| Address2: | 4302 ALLEN RD SUITE 301 | ||||||||
| City: | STOW | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442241070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3309457246 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4302 ALLEN RD STE 300 | ||||||||
| Address2: | 4302 ALLEN RD SUITE 301 | ||||||||
| City: | STOW | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442241070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3309457246 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2011 | ||||||||
| LastUpdateDate: | 11/03/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WOOD | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACY MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3309454346 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | 022097600 | OH | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 3679896 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER |