Basic Information
| Provider Information | |||||||||
| NPI: | 1659391373 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUMMERS | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 MORRIS ST STE 400 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253011854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043434583 | ||||||||
| FaxNumber: | 3043439207 | ||||||||
| Practice Location | |||||||||
| Address1: | 4301 MACCORKLE AVE S.E. | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047209185 | ||||||||
| FaxNumber: | 3047209186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 09/02/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 000879 | WV | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 000000217253 | 01 | ANTHEM BCBS | OTHER | 0157001000 | 05 | WV | MEDICAID | 650019724 | 01 | RR MEDICARE | OTHER | 001720895 | 01 | MOUNTAIN STATE BCBS | OTHER |