1679791404 NPI number — SILVER SUMMIT MEDICAL CORPORATION

Table of content: (NPI 1679791404)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679791404 NPI number — SILVER SUMMIT MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SILVER SUMMIT MEDICAL CORPORATION
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:
6
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:
1679791404
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/16/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 748792
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90074-8792
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
661-864-3664
Provider Business Mailing Address Fax Number:
661-328-2925

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1408 COMMERCIAL WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAKERSFIELD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93309-0407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
661-327-4455
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/24/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MEYER
Authorized Official First Name:
MADELINE
Authorized Official Middle Name:
ANGELA
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
321-274-8344

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  A45356 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: SUR1315F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1679791404 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".