Basic Information
| Provider Information | |||||||||
| NPI: | 1083093686 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUMMIT PHYSICIAN SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WELLSPAN WEIGHT MANAGEMENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 12 ST PAUL DR | ||||||||
| Address2: | |||||||||
| City: | CHAMBERSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 172011035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172672427 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2015 | ||||||||
| LastUpdateDate: | 06/24/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HINCKLE | ||||||||
| AuthorizedOfficialFirstName: | LISSA | ||||||||
| AuthorizedOfficialMiddleName: | N. | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VP OF PHYSICIAN SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 7172674839 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUMMIT PHYSICIAN SERVICES | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207QB0002X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Bariatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1007307260076 | 05 | PA | MEDICAID | 1007307260139 | 05 | PA | MEDICAID | 1007307260122 | 05 | PA | MEDICAID | 1007307260143 | 05 | PW | MEDICAID |