Basic Information
| Provider Information | |||||||||
| NPI: | 1942532825 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUMMIT MEDICAL GROUP | ||||||||
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| OtherOrganizationName: | DBA PATIENT FIRST DIGESTIVE DISEASE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 334 THOMAS MORE PKWY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CRESTVIEW HILLS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593445481 | ||||||||
| FaxNumber: | 8593445552 | ||||||||
| Practice Location | |||||||||
| Address1: | 340 THOMAS MORE PKWY | ||||||||
| Address2: | SUITE 160 B | ||||||||
| City: | CRESTVIEW HILLS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410175100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593316466 | ||||||||
| FaxNumber: | 8593311932 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2010 | ||||||||
| LastUpdateDate: | 08/17/2010 | ||||||||
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| AuthorizedOfficialLastName: | BERTE | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
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| AuthorizedOfficialTitleorPosition: | C.O.O. | ||||||||
| AuthorizedOfficialTelephone: | 8599571080 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUMMIT MEDICAL GROUP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 300131 | KY | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | P00815268 | 01 | RAILRAOD MEDICARE | OTHER | 7100123490 | 05 | KY | MEDICAID |