Provider Demographics
NPI:1366819112
Name:SUMMIT FOOT AND ANKLE SPECIALISTS
Entity Type:Organization
Organization Name:SUMMIT FOOT AND ANKLE SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-784-1111
Mailing Address - Street 1:1355 N UNIVERSITY AVE
Mailing Address - Street 2:SUITE 125
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-2721
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1355 N UNIVERSITY AVE
Practice Address - Street 2:SUITE 125
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-2721
Practice Address - Country:US
Practice Address - Phone:801-784-1111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-27
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric