Basic Information
| Provider Information | |||||||||
| NPI: | 1427200021 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUMMIT ORTHOPAEDICS, LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4103 MERCANTILE DR | ||||||||
| Address2: | |||||||||
| City: | LAKE OSWEGO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970352556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038509940 | ||||||||
| FaxNumber: | 5038506725 | ||||||||
| Practice Location | |||||||||
| Address1: | 4103 MERCANTILE DR | ||||||||
| Address2: | |||||||||
| City: | LAKE OSWEGO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038509940 | ||||||||
| FaxNumber: | 5038506725 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2008 | ||||||||
| LastUpdateDate: | 06/25/2021 | ||||||||
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| AuthorizedOfficialLastName: | GUEST | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMIN | ||||||||
| AuthorizedOfficialTelephone: | 5038509940 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 500616835 | 05 | OR | MEDICAID |