1740457332 NPI number — MICHAEL G. SUMMERS DDS, MS, PA

Table of content: (NPI 1740457332)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740457332 NPI number — MICHAEL G. SUMMERS DDS, MS, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHAEL G. SUMMERS DDS, MS, PA
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:
1740457332
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1133 CALL CREEK
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
POCATELLO
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-232-0464
Provider Business Mailing Address Fax Number:
208-232-0863

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1133 CALL CREEK
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-232-0464
Provider Business Practice Location Address Fax Number:
208-232-0863
Provider Enumeration Date:
05/13/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SUMMERS
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
208-232-0464

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  D-3284-OR , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 963311 . This is a "INSURANCE CO." identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 645574 . This is a "UNITED CONCORDIA INS. CO." identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 6G405 . This is a "INSURANCE CO." identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 9202522 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 963311 . This is a "UNITED CONCORDIA INSURANCE CO." identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000015300 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 805033500 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9201874 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6G421 . This is a "INSURANCE CO." identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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