1598469462 NPI number — SUMMIT MEMORIAL MEDICAL GROUP LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598469462 NPI number — SUMMIT MEMORIAL MEDICAL GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUMMIT MEMORIAL MEDICAL GROUP LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598469462
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/16/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
222 S 5TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOUGLAS
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82633-2534
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-358-1459
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6500 E 2ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CASPER
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82609-4338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-577-1000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/27/2023

Additional Information

Authorized Official

Authorized Official Last Name:
CUSSINS
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
307-286-6738

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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