Basic Information
| Provider Information | |||||||||
| NPI: | 1487958153 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUMMIT SPINE & NEUROSURGERY ASSOCIATES PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2301 HOUSE AVE | ||||||||
| Address2: | SUITE 505 | ||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820013176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076329261 | ||||||||
| FaxNumber: | 8888697201 | ||||||||
| Practice Location | |||||||||
| Address1: | 2301 HOUSE AVE | ||||||||
| Address2: | SUITE 505 | ||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820013176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076329261 | ||||||||
| FaxNumber: | 8888697201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2011 | ||||||||
| LastUpdateDate: | 01/10/2011 | ||||||||
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| AuthorizedOfficialLastName: | CARTER | ||||||||
| AuthorizedOfficialFirstName: | DARCY | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING | ||||||||
| AuthorizedOfficialTelephone: | 3076314212 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MISS | ||||||||
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| AuthorizedOfficialCredential: | CPC CCSP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | 6709A | WY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 119195100 | 05 | WY | MEDICAID | P00135442 | 01 | WY | RAILROAD MEDICARE | OTHER |