Provider Demographics
NPI:1649262825
Name:SUMMIT HEALTH PROFESSIONALS
Entity type:Organization
Organization Name:SUMMIT HEALTH PROFESSIONALS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:NIKOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-524-4953
Mailing Address - Street 1:3760 WASHINGTON PKWY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7593
Mailing Address - Country:US
Mailing Address - Phone:208-524-4953
Mailing Address - Fax:208-524-7335
Practice Address - Street 1:3760 WASHINGTON PKWY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7593
Practice Address - Country:US
Practice Address - Phone:208-524-4953
Practice Address - Fax:208-524-7335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-16
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-1311104100000X
IDLCPC-323101Y00000X
IDM86212084P0800X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806797700Medicaid
H19414Medicare UPIN
1105722Medicare ID - Type Unspecified
ID806797700Medicaid