Provider Demographics
NPI:1710143607
Name:SUMMIT HEALTHCARE ASSOCIATION
Entity Type:Organization
Organization Name:SUMMIT HEALTHCARE ASSOCIATION
Other - Org Name:SUMMIT HEALTHCARE SPECIALTY PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CCO
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-537-6399
Mailing Address - Street 1:2200 E SHOW LOW LAKE RD
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-7831
Mailing Address - Country:US
Mailing Address - Phone:928-537-6399
Mailing Address - Fax:928-537-8839
Practice Address - Street 1:2200 E SHOW LOW LAKE RD
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7831
Practice Address - Country:US
Practice Address - Phone:928-537-6399
Practice Address - Fax:928-537-8839
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUMMIT HEALTHCARE ASSOCIATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-31
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZH0132207L00000X, 207RH0003X, 207RX0202X, 2085R0001X, 208VP0000X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282N00000XHospitalsGeneral Acute Care Hospital
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Single Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ020016Medicaid
AZ030062Medicare Oscar/Certification