Provider Demographics
NPI:1265655633
Name:SUMMIT PHYSICIAN SERVICES
Entity Type:Organization
Organization Name:SUMMIT PHYSICIAN SERVICES
Other - Org Name:WELLSPAN PLASTIC SURGERY & SKIN CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VP OF PHYSICIAN SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:LISSA
Authorized Official - Middle Name:N
Authorized Official - Last Name:HINCKLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-267-4839
Mailing Address - Street 1:785 5TH AVENUE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17201-4232
Mailing Address - Country:US
Mailing Address - Phone:717-263-9555
Mailing Address - Fax:717-217-4217
Practice Address - Street 1:12 ST PAUL DR STE 104
Practice Address - Street 2:
Practice Address - City:CHAMBERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17201-1033
Practice Address - Country:US
Practice Address - Phone:717-263-8463
Practice Address - Fax:717-263-1103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4513412086S0122X
PAMA052608363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007307260071Medicaid
PA1007307260071Medicaid