Provider Demographics
NPI:1558497008
Name:SUMMIT OF DETROIT, P.C.
Entity Type:Organization
Organization Name:SUMMIT OF DETROIT, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANISE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BURRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-272-8450
Mailing Address - Street 1:15801 W MCNICHOLS
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-3543
Mailing Address - Country:US
Mailing Address - Phone:313-272-8450
Mailing Address - Fax:313-272-8455
Practice Address - Street 1:15801 W MCNICHOLS
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-3543
Practice Address - Country:US
Practice Address - Phone:313-272-8450
Practice Address - Fax:313-272-8455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801072558104100000X
MI861501133V00000X
MI4704191117163W00000X
MI4301028327207V00000X
MI4301030345207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI160Q260450OtherBCBSM
MI3802006439OtherEIN
MI4404690OtherSTATE OF MI MEDICAID