Basic Information
Provider Information | |||||||||
NPI: | 1376911701 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SUMMIT PHYSICIAN SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WELLSPAN FAST CARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 785 5TH AVE | ||||||||
Address2: | SUITE 3 | ||||||||
City: | CHAMBERSBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 172014232 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7172639555 | ||||||||
FaxNumber: | 7172174218 | ||||||||
Practice Location | |||||||||
Address1: | GIANT | ||||||||
Address2: | 993 WAYNE AVENUE | ||||||||
City: | CHAMBERSBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 172013895 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7172643278 | ||||||||
FaxNumber: | 7172624494 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/02/2015 | ||||||||
LastUpdateDate: | 11/29/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HINCKLE | ||||||||
AuthorizedOfficialFirstName: | LISSA | ||||||||
AuthorizedOfficialMiddleName: | N. | ||||||||
AuthorizedOfficialTitleorPosition: | SENIOR VP OF PHYSICIAN SERVICES | ||||||||
AuthorizedOfficialTelephone: | 7172674839 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X |   | PA | N |   | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261Q00000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
ID Information
ID | Type | State | Issuer | Description | 1007307260080 | 05 | PA |   | MEDICAID |