Provider Demographics
NPI:1184205379
Name:SUMMIT CITY PROSTHETICS & ORTHOTICS INC
Entity Type:Organization
Organization Name:SUMMIT CITY PROSTHETICS & ORTHOTICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:DEE
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:260-312-1746
Mailing Address - Street 1:16597 STATE ROAD 23 STE 2
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1461
Mailing Address - Country:US
Mailing Address - Phone:574-855-1488
Mailing Address - Fax:574-387-5583
Practice Address - Street 1:16597 STATE ROAD 23 STE 2
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1461
Practice Address - Country:US
Practice Address - Phone:574-855-1488
Practice Address - Fax:574-387-5583
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUMMIT CITY PROSTHETICS & ORTHOTICS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300033323Medicaid