1497125868 NPI number — SUMMIT HEALTH GROUP INC

Table of content: JOHNATHON ANTONIO MONTREL TUCKER PA (NPI 1912767674)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497125868 NPI number — SUMMIT HEALTH GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUMMIT HEALTH GROUP INC
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:
1497125868
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/08/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
55 ROLLING OAKS DR
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
THOUSAND OAKS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91361-1010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-499-4446
Provider Business Mailing Address Fax Number:
805-499-3636

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
55 ROLLING OAKS DR
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
THOUSAND OAKS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91361-1010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-499-4446
Provider Business Practice Location Address Fax Number:
805-499-3636
Provider Enumeration Date:
09/29/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MCDERMOTT
Authorized Official First Name:
DANNELLE
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
805-499-4446

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 171100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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