Provider Demographics
NPI:1558630020
Name:SUMMIT PAIN ALLIANCE INC
Entity Type:Organization
Organization Name:SUMMIT PAIN ALLIANCE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:I
Authorized Official - Last Name:YANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-623-9803
Mailing Address - Street 1:392 TESCONI CT
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-4653
Mailing Address - Country:US
Mailing Address - Phone:707-623-9803
Mailing Address - Fax:
Practice Address - Street 1:392 TESCONI CT
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4653
Practice Address - Country:US
Practice Address - Phone:707-623-9803
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-29
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA112702174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFS634AOtherMEDICARE PTAN