Provider Demographics
NPI:1235344060
Name:SUMMIT MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:SUMMIT MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN AND SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:A
Authorized Official - Last Name:LINDSEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-307-1422
Mailing Address - Street 1:PO BOX 22165
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97269-2165
Mailing Address - Country:US
Mailing Address - Phone:503-307-1422
Mailing Address - Fax:
Practice Address - Street 1:12633 SE OATFIELD RD
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-6939
Practice Address - Country:US
Practice Address - Phone:503-307-1422
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17146207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1932162880OtherMEDICARE NPI
OR1235344060OtherMEDICARE NPI
OR287403Medicaid
OR715535-81OtherOREGON STATE BUSINESS LIC
OR1922074160OtherMEDICARE NPI
OR1922074160OtherMEDICARE NPI
OR715535-81OtherOREGON STATE BUSINESS LIC
ORR134276Medicare PIN