Provider Demographics
NPI:1760414247
Name:SUMMIT REHABILITATION MEDICINE, INC.
Entity Type:Organization
Organization Name:SUMMIT REHABILITATION MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNARD
Authorized Official - Middle Name:
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:234-678-9332
Mailing Address - Street 1:PO BOX 14807
Mailing Address - Street 2:
Mailing Address - City:COPLEY
Mailing Address - State:OH
Mailing Address - Zip Code:44321-4807
Mailing Address - Country:US
Mailing Address - Phone:234-678-9332
Mailing Address - Fax:
Practice Address - Street 1:4389 MEDINA RD
Practice Address - Street 2:
Practice Address - City:COPLEY
Practice Address - State:OH
Practice Address - Zip Code:44321-1388
Practice Address - Country:US
Practice Address - Phone:234-678-9332
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0786823Medicaid
OH0786823Medicaid
OH9930273Medicare PIN
OHCB0553Medicare PIN