Provider Demographics
NPI:1235275207
Name:SUMMIT MEDICAL GROUP
Entity Type:Organization
Organization Name:SUMMIT MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:STUART
Authorized Official - Last Name:KERZNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-331-5320
Mailing Address - Street 1:100 HIGHLAND AVE STE 307
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-2753
Mailing Address - Country:US
Mailing Address - Phone:401-331-5320
Mailing Address - Fax:401-331-6168
Practice Address - Street 1:100 HIGHLAND AVE STE 307
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-2753
Practice Address - Country:US
Practice Address - Phone:401-331-5320
Practice Address - Fax:401-331-6168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRI3593261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI847-1OtherBLUE CROSS
RI9000847Medicaid
RI2059883OtherAETNA
RI2059883OtherAETNA