Basic Information
| Provider Information | |||||||||
| NPI: | 1548536568 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUMMIT MEDICAL GROUP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST. ELIZABETH PHYSICIANS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 CHAMBER CENTER DR | ||||||||
| Address2: | SU. 200 | ||||||||
| City: | LAKESIDE PARK | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410171673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593445555 | ||||||||
| FaxNumber: | 8593445552 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 COMMERCIAL DR | ||||||||
| Address2: | |||||||||
| City: | ALEXANDRIA | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410012107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8596359440 | ||||||||
| FaxNumber: | 8594482622 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2012 | ||||||||
| LastUpdateDate: | 03/23/2012 | ||||||||
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| AuthorizedOfficialLastName: | LOOMIS | ||||||||
| AuthorizedOfficialFirstName: | GLENN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 8593443733 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.