Provider Demographics
NPI:1154322410
Name:SUMMIT SURGICAL SUITES, LLC
Entity Type:Organization
Organization Name:SUMMIT SURGICAL SUITES, LLC
Other - Org Name:SOUTHWEST SURGICAL SUITES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:HADDIX
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:260-434-2022
Mailing Address - Street 1:7920 W JEFFERSON BLVD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4168
Mailing Address - Country:US
Mailing Address - Phone:260-434-2022
Mailing Address - Fax:260-434-2023
Practice Address - Street 1:7920 W JEFFERSON BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4168
Practice Address - Country:US
Practice Address - Phone:260-434-2022
Practice Address - Fax:260-434-2023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05-003212-1261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200413500Medicaid
IN13443OtherPHP PROVIDER NUMBER
INZG4050Medicare PIN