Provider Demographics
NPI:1770700767
Name:SUMMIT HEALTHCARE MEDICAL ASSOCIATES
Entity type:Organization
Organization Name:SUMMIT HEALTHCARE MEDICAL ASSOCIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HEALTH PLAN CREDENTIALING COORDINAT
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:BLUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-537-6393
Mailing Address - Street 1:PO BOX 1013
Mailing Address - Street 2:
Mailing Address - City:OVERGAARD
Mailing Address - State:AZ
Mailing Address - Zip Code:85933-1013
Mailing Address - Country:US
Mailing Address - Phone:928-535-3616
Mailing Address - Fax:928-532-2156
Practice Address - Street 1:2352 QUARTER HORSE TRAIL
Practice Address - Street 2:
Practice Address - City:OVERGAARD
Practice Address - State:AZ
Practice Address - Zip Code:85933
Practice Address - Country:US
Practice Address - Phone:928-535-3616
Practice Address - Fax:928-532-2156
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUMMIT HEALTHCARE ASSOCIATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-19
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZH0132261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ950222Medicaid
AZ020016Medicaid