Basic Information
| Provider Information | |||||||||
| NPI: | 1942701693 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUMMIT HEALTHCARE MEDICAL ASSOCIATES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SUMMIT HEALTHCARE PEDIATRICS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3050 | ||||||||
| Address2: | |||||||||
| City: | SHOW LOW | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859023050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285376393 | ||||||||
| FaxNumber: | 9285376725 | ||||||||
| Practice Location | |||||||||
| Address1: | 4951 S WHITE MOUNTAIN RD BLDG A | ||||||||
| Address2: | |||||||||
| City: | SHOW LOW | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859017801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2895376700 | ||||||||
| FaxNumber: | 9285322159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2018 | ||||||||
| LastUpdateDate: | 12/09/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ALLEN | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | ROBERT | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF PRACTICE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9285374375 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUMMIT HEALTHCARE ASSOCIATION | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/09/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.