Provider Demographics
NPI:1083736128
Name:SUMMIT HEALTHCARE ASSOCIATION
Entity Type:Organization
Organization Name:SUMMIT HEALTHCARE ASSOCIATION
Other - Org Name:SUMMIT HEALTHCARE ONCOLOGY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-537-6399
Mailing Address - Street 1:2500 E HUNT ST
Mailing Address - Street 2:SUITE H
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-7954
Mailing Address - Country:US
Mailing Address - Phone:928-537-6937
Mailing Address - Fax:
Practice Address - Street 1:2500 E HUNT ST
Practice Address - Street 2:SUITE H
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7954
Practice Address - Country:US
Practice Address - Phone:928-537-6937
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUMMIT HEALTHCARE ASSOCIATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-06
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3376261QX0200X, 261QX0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0200XAmbulatory Health Care FacilitiesClinic/CenterOncology
No261QX0203XAmbulatory Health Care FacilitiesClinic/CenterOncology, Radiation
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ020016Medicaid
AZ020016Medicaid