Provider Demographics
NPI:1629291893
Name:SUMMIT DERMATOLOGY, P.C.
Entity Type:Organization
Organization Name:SUMMIT DERMATOLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:WHALEY
Authorized Official - Suffix:I
Authorized Official - Credentials:MD
Authorized Official - Phone:719-667-0888
Mailing Address - Street 1:8890 N UNION BLVD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-7799
Mailing Address - Country:US
Mailing Address - Phone:719-667-0888
Mailing Address - Fax:719-667-0808
Practice Address - Street 1:8890 N UNION BLVD
Practice Address - Street 2:SUITE 207
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-7799
Practice Address - Country:US
Practice Address - Phone:719-667-0888
Practice Address - Fax:719-667-0808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO33020174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO95411Medicare PIN