Provider Demographics
NPI:1972779361
Name:SUMMERS, STEPHANIE
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:
Last Name:SUMMERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1594 KENILWORTH DR
Mailing Address - Street 2:
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-6306
Mailing Address - Country:US
Mailing Address - Phone:773-425-8243
Mailing Address - Fax:773-667-9622
Practice Address - Street 1:1594 KENILWORTH DR
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-6306
Practice Address - Country:US
Practice Address - Phone:773-425-8243
Practice Address - Fax:773-667-9622
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-05
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILS56278166683172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL343729196040901Medicaid