1235344060 NPI number — SUMMIT MEDICAL GROUP, LLC

Table of content: (NPI 1235344060)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235344060 NPI number — SUMMIT MEDICAL GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUMMIT 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:
1235344060
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 22165
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILWAUKIE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97269-2165
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-307-1422
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12633 SE OATFIELD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILWAUKIE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97222-6939
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-307-1422
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LINDSEY
Authorized Official First Name:
JUDITH
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PHYSICIAN AND SURGEON
Authorized Official Telephone Number:
503-307-1422

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  17146 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1932162880 . This is a "MEDICARE NPI" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 1235344060 . This is a "MEDICARE NPI" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 287403 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 715535-81 . This is a "OREGON STATE BUSINESS LIC" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 1922074160 . This is a "MEDICARE NPI" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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