Provider Demographics
NPI:1942325402
Name:SUMMIT CANCER CARE PC
Entity Type:Organization
Organization Name:SUMMIT CANCER CARE PC
Other - Org Name:SUMMIT CANCER CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES, MD, AO
Authorized Official - Prefix:
Authorized Official - First Name:L
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:912-651-5767
Mailing Address - Street 1:836 E 65TH ST STE 4
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-4491
Mailing Address - Country:US
Mailing Address - Phone:912-354-6187
Mailing Address - Fax:
Practice Address - Street 1:836 E 65TH ST STE 4
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-4491
Practice Address - Country:US
Practice Address - Phone:912-651-5767
Practice Address - Fax:912-354-7090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
GAPHRE0090513336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00165459AMedicaid
2015659OtherPK
GA00165459AMedicaid