Basic Information
| Provider Information | |||||||||
| NPI: | 1477104552 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUMMIT HEALTHCARE ASSOCIATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 E SHOW LOW LAKE RD | ||||||||
| Address2: | |||||||||
| City: | SHOW LOW | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859017831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285376393 | ||||||||
| FaxNumber: | 9285322131 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 E SHOW LOW LAKE RD | ||||||||
| Address2: | |||||||||
| City: | SHOW LOW | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859017831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285376393 | ||||||||
| FaxNumber: | 9285322131 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2019 | ||||||||
| LastUpdateDate: | 09/20/2019 | ||||||||
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| AuthorizedOfficialLastName: | BLUSE | ||||||||
| AuthorizedOfficialFirstName: | JILL | ||||||||
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| AuthorizedOfficialTitleorPosition: | HEALTH PLAN CREDENTIALING COORDINAT | ||||||||
| AuthorizedOfficialTelephone: | 9285376393 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUMMIT HEALTHCARE ASSOCIATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | Y | Hospital Units | Psychiatric Unit |
No ID Information.