Basic Information
| Provider Information | |||||||||
| NPI: | 1750343216 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUMMIT MEDICAL GROUP, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST. ELIZABETH PHYSICIANS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1360 DOLWICK DRIVE | ||||||||
| Address2: | |||||||||
| City: | ERLANGER | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410183127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593445555 | ||||||||
| FaxNumber: | 8593445552 | ||||||||
| Practice Location | |||||||||
| Address1: | 1360 DOLWICK DRIVE | ||||||||
| Address2: | |||||||||
| City: | ERLANGER | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410183127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593445555 | ||||||||
| FaxNumber: | 8593445552 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2006 | ||||||||
| LastUpdateDate: | 09/08/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RANKIN | ||||||||
| AuthorizedOfficialFirstName: | MARIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | AVP-REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 8593445555 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 104100000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 106H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 133V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 152W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 213ES0103X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 261QU0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2355115 | 05 | OH | MEDICAID | 2501152300 | 05 | IN | MEDICAID | 200993310 | 05 | IN | MEDICAID | 201157570 | 05 | IN | MEDICAID | 7100235410 | 05 | KY | MEDICAID | 78003852 | 05 | KY | MEDICAID | CC3684 | 01 | KY | RAILROAD | OTHER | 201152300 | 05 | IN | MEDICAID | 7100018930 | 05 | KY | MEDICAID | DQ9133 | 01 | OH | RAILROAD | OTHER | 65926743 | 05 | KY | MEDICAID | 7100235400 | 05 | KY | MEDICAID | 7100271890 | 05 | KY | MEDICAID | 7100311260 | 05 | KY | MEDICAID | DR8623 | 01 | IN | RAILROAD | OTHER | 78902020 | 05 | KY | MEDICAID |