1649559964 NPI number — SUMMA PHYSICIANS INC

Table of content: (NPI 1649559964)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649559964 NPI number — SUMMA PHYSICIANS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUMMA PHYSICIANS 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:
1649559964
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/05/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
525 E MARKET ST
Provider Second Line Business Mailing Address:
PO BOX 2090
Provider Business Mailing Address City Name:
AKRON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44304-1619
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-996-8603
Provider Business Mailing Address Fax Number:
330-996-8695

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3780 MEDINA RD
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
MEDINA
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44256-9311
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-379-5051
Provider Business Practice Location Address Fax Number:
330-379-5074
Provider Enumeration Date:
08/04/2011

Additional Information

Authorized Official

Authorized Official Last Name:
FREDERICKS
Authorized Official First Name:
BRYAN
Authorized Official Middle Name:
L
Authorized Official Title or Position:
CHIEF OPERATING OFFICER
Authorized Official Telephone Number:
330-996-8603

Provider Taxonomy Codes

  • Taxonomy code: 207QS0010X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0055648 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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