Basic Information
| Provider Information | |||||||||
| NPI: | 1043620933 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUMMIT PHYSICIAN SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WELLSPAN URGENT CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 785 5TH AVE | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | CHAMBERSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 172014232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172639555 | ||||||||
| FaxNumber: | 7172174218 | ||||||||
| Practice Location | |||||||||
| Address1: | 46 WALNUT BOTTOM RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SHIPPENSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 172578219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7174772764 | ||||||||
| FaxNumber: | 7172174207 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2014 | ||||||||
| LastUpdateDate: | 12/02/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HINCKLE | ||||||||
| AuthorizedOfficialFirstName: | LISSA | ||||||||
| AuthorizedOfficialMiddleName: | N. | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VP OF PHYSICIAN SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 7177094764 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUMMIT HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 1007307260061 | 05 | PA | MEDICAID |