Basic Information
| Provider Information | |||||||||
| NPI: | 1770700767 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUMMIT HEALTHCARE MEDICAL ASSOCIATES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FAMILY MEDICINE AT BISON RANCH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1013 | ||||||||
| Address2: | |||||||||
| City: | OVERGAARD | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859331013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285353616 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2352 QUARTER HORSE TRAIL | ||||||||
| Address2: | |||||||||
| City: | OVERGAARD | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285353616 | ||||||||
| FaxNumber: | 9285353615 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2007 | ||||||||
| LastUpdateDate: | 06/24/2019 | ||||||||
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| AuthorizedOfficialLastName: | BLUSE | ||||||||
| AuthorizedOfficialFirstName: | JILL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | HEALTH PLAN CREDENTIALING COORDINAT | ||||||||
| AuthorizedOfficialTelephone: | 9285376393 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUMMIT HEALTHCARE ASSOCIATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | H0132 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 950222 | 05 | AZ | MEDICAID |