Provider Demographics
NPI:1659391373
Name:SUMMERS, STEPHEN L (PT)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:L
Last Name:SUMMERS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 MORRIS ST STE 400
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1854
Mailing Address - Country:US
Mailing Address - Phone:304-343-4583
Mailing Address - Fax:304-343-9207
Practice Address - Street 1:4301 MACCORKLE AVE S.E.
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304
Practice Address - Country:US
Practice Address - Phone:304-720-9185
Practice Address - Fax:304-720-9186
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV000879225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000217253OtherANTHEM BCBS
WV0157001000Medicaid
650019724OtherRR MEDICARE
001720895OtherMOUNTAIN STATE BCBS
650019724OtherRR MEDICARE
000000217253OtherANTHEM BCBS
WV0157001000Medicaid