Basic Information
| Provider Information | |||||||||
| NPI: | 1679744643 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUMMIT MEDICAL CENTER S.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | SUMMIT MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6252 S ARCHER RD | ||||||||
| Address2: | |||||||||
| City: | SUMMIT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605011720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084969549 | ||||||||
| FaxNumber: | 7087289429 | ||||||||
| Practice Location | |||||||||
| Address1: | 6252 S ARCHER RD | ||||||||
| Address2: | |||||||||
| City: | SUMMIT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605011720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084969549 | ||||||||
| FaxNumber: | 7087289429 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2008 | ||||||||
| LastUpdateDate: | 08/29/2022 | ||||||||
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| AuthorizedOfficialLastName: | SHAH | ||||||||
| AuthorizedOfficialFirstName: | ANKIT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7084969549 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 08/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 036086195 | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 036086195 | 05 | IL | MEDICAID |