Provider Demographics
NPI:1124044607
Name:SUMMIT RADIOLOGY SERVICES LLC
Entity Type:Organization
Organization Name:SUMMIT RADIOLOGY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:A
Authorized Official - Last Name:TUCKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-449-7984
Mailing Address - Street 1:3738 LANDMARK DR.
Mailing Address - Street 2:SUITE D
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-6655
Mailing Address - Country:US
Mailing Address - Phone:765-449-7984
Mailing Address - Fax:765-449-9791
Practice Address - Street 1:3738 LANDMARK DR.
Practice Address - Street 2:SUITE D
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-6655
Practice Address - Country:US
Practice Address - Phone:765-449-7984
Practice Address - Fax:765-449-9791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200020370BMedicaid
WI31714000OtherMEDICAID
KY64882822OtherMEDICAID
KY64882822OtherMEDICAID