Provider Demographics
NPI:1508229584
Name:SUMMIT MEDICAL CARE CENTER, LLC
Entity Type:Organization
Organization Name:SUMMIT MEDICAL CARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:303-466-3232
Mailing Address - Street 1:54 GARDEN CTR
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-1730
Mailing Address - Country:US
Mailing Address - Phone:303-466-3232
Mailing Address - Fax:303-466-0110
Practice Address - Street 1:54 GARDEN CTR
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-1730
Practice Address - Country:US
Practice Address - Phone:303-466-3232
Practice Address - Fax:303-466-0110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-29
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN-0991919-NP208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COG8931030Medicare PIN
COAA38676253Medicare PIN
COC469108Medicare PIN