Provider Demographics
NPI:1275659849
Name:SUMMIT PODIATRY INC
Entity Type:Organization
Organization Name:SUMMIT PODIATRY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DPM OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:R
Authorized Official - Last Name:GLASER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:910-791-1300
Mailing Address - Street 1:4113 OLEANDER DR
Mailing Address - Street 2:SUITE G
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-6839
Mailing Address - Country:US
Mailing Address - Phone:910-791-1300
Mailing Address - Fax:910-791-4125
Practice Address - Street 1:4113 OLEANDER DR
Practice Address - Street 2:SUITE G
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6839
Practice Address - Country:US
Practice Address - Phone:910-791-1300
Practice Address - Fax:791-791-4125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC116213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC23656OtherMEDCOST
NC480922078OtherRAILROAD MEDICARE
NC2728879OtherUNITED HEALTHCARE
NC890802RMedicaid
NY0071418-99OtherGHI
NYP02480-31OtherNY WORKERS COMP
NC004264925OtherAETNA
NC0802ROtherBLUE CROSS BLUE SHIELD
NC1659398OtherOXFORD HEALTH UHC
NC0802ROtherBLUE CROSS BLUE SHIELD
NYP02480-31OtherNY WORKERS COMP
NCT50788Medicare UPIN