Provider Demographics
NPI:1649368085
Name:SUMMIT ANESTHESIA, LLC
Entity type:Organization
Organization Name:SUMMIT ANESTHESIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GROUP MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MUHAMMOD
Authorized Official - Middle Name:A
Authorized Official - Last Name:AHMAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-567-2180
Mailing Address - Street 1:PO BOX 11535
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46859-1535
Mailing Address - Country:US
Mailing Address - Phone:317-567-2180
Mailing Address - Fax:317-567-2191
Practice Address - Street 1:700 BROADWAY
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-1402
Practice Address - Country:US
Practice Address - Phone:260-969-1950
Practice Address - Fax:260-969-0989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200843170AMedicaid
IN200843170AMedicaid