Provider Demographics
NPI:1093368789
Name:SUMMIT HEALTHCARE MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:SUMMIT HEALTHCARE MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-537-4375
Mailing Address - Street 1:728 E WHITE MOUNTAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:PINETOP
Mailing Address - State:AZ
Mailing Address - Zip Code:85929
Mailing Address - Country:US
Mailing Address - Phone:952-653-2565
Mailing Address - Fax:952-653-2540
Practice Address - Street 1:728 E WHITE MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:PINETOP
Practice Address - State:AZ
Practice Address - Zip Code:85929
Practice Address - Country:US
Practice Address - Phone:952-653-2565
Practice Address - Fax:952-653-2540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-22
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty