Provider Demographics
NPI:1821013509
Name:SUMMIT GASTROENTEROLOGY LLC
Entity type:Organization
Organization Name:SUMMIT GASTROENTEROLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:ASTEL
Authorized Official - Last Name:WALLER
Authorized Official - Suffix:
Authorized Official - Credentials:APRN BC
Authorized Official - Phone:816-554-3838
Mailing Address - Street 1:20 NE SAINT LUKES BLVD
Mailing Address - Street 2:SUITE #330
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64086
Mailing Address - Country:US
Mailing Address - Phone:816-554-3838
Mailing Address - Fax:816-554-1634
Practice Address - Street 1:20 NE SAINT LUKES BLVD
Practice Address - Street 2:SUITE #330
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64086
Practice Address - Country:US
Practice Address - Phone:816-554-3838
Practice Address - Fax:816-554-1634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO507580405Medicaid
MO507580405Medicaid