Basic Information
| Provider Information | |||||||||
| NPI: | 1871578229 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUMMIT COUNTY INTENSIVE CARE PHYSICIANS INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 525 E MARKET ST | ||||||||
| Address2: | SUITE 1N | ||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443041619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303753588 | ||||||||
| FaxNumber: | 3303757615 | ||||||||
| Practice Location | |||||||||
| Address1: | 525 E MARKET ST | ||||||||
| Address2: | SUITE 1N | ||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443041619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303753588 | ||||||||
| FaxNumber: | 3303757615 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MARTIN | ||||||||
| AuthorizedOfficialFirstName: | BRADLEY | ||||||||
| AuthorizedOfficialMiddleName: | RENE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3303753588 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD FACP FACPE | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0702967 | 05 | OH | MEDICAID |