Basic Information
| Provider Information | |||||||||
| NPI: | 1740934678 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUMMIT HEALTHCARE MEDICAL ASSOCIATES | ||||||||
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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: | 1401 W FLORIDA ST | ||||||||
| Address2: | |||||||||
| City: | HOLBROOK | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860252218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285242020 | ||||||||
| FaxNumber: | 9285243755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2022 | ||||||||
| LastUpdateDate: | 02/09/2022 | ||||||||
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| AuthorizedOfficialLastName: | ALLEN | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | ROBERT | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF PRACTICE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9285374375 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUMMIT HEALTHCARE ASSOCIATION | ||||||||
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| NPICertificationDate: | 02/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.