Provider Demographics
NPI:1821191438
Name:SUMMIT PEDIATRIC MEDICAL GROUP INC
Entity Type:Organization
Organization Name:SUMMIT PEDIATRIC MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LLOYD
Authorized Official - Middle Name:HEISABURO
Authorized Official - Last Name:TAKAO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-254-9500
Mailing Address - Street 1:4 COUNTRY CLUB PLAZA
Mailing Address - Street 2:
Mailing Address - City:ORINDA
Mailing Address - State:CA
Mailing Address - Zip Code:94563-2308
Mailing Address - Country:US
Mailing Address - Phone:925-254-9500
Mailing Address - Fax:925-254-9505
Practice Address - Street 1:4 COUNTRY CLUB PLAZA
Practice Address - Street 2:
Practice Address - City:ORINDA
Practice Address - State:CA
Practice Address - Zip Code:94563-2308
Practice Address - Country:US
Practice Address - Phone:925-254-9500
Practice Address - Fax:925-254-9505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty