Provider Demographics
NPI:1043782287
Name:SUMMIT MEDICAL GROUP WEST FLORIDA
Entity Type:Organization
Organization Name:SUMMIT MEDICAL GROUP WEST FLORIDA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYSLETT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:727-709-0550
Mailing Address - Street 1:2410 NORTHSIDE DR
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33761-2236
Mailing Address - Country:US
Mailing Address - Phone:727-499-0351
Mailing Address - Fax:727-781-3312
Practice Address - Street 1:11125 PARK BLVD STE 104
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33772-4700
Practice Address - Country:US
Practice Address - Phone:727-709-0550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-28
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty