Provider Demographics
NPI:1114336781
Name:SUMMIT SPINE AND NEUROSURGERY ASSOCIATES
Entity Type:Organization
Organization Name:SUMMIT SPINE AND NEUROSURGERY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:GAUTREAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-773-8012
Mailing Address - Street 1:2301 HOUSE AVE
Mailing Address - Street 2:SUITE 505
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-3176
Mailing Address - Country:US
Mailing Address - Phone:307-632-9261
Mailing Address - Fax:307-634-9170
Practice Address - Street 1:2301 HOUSE AVE
Practice Address - Street 2:SUITE 505
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3176
Practice Address - Country:US
Practice Address - Phone:307-632-9261
Practice Address - Fax:307-634-9170
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHEYENNE REGIONAL MEDICAL GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-08-08
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty