Healthcare Provider Details

I. General information

NPI: 1740934678
Provider Name (Legal Business Name): SUMMIT HEALTHCARE MEDICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2022
Last Update Date: 02/09/2022
Certification Date: 02/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 W FLORIDA ST
HOLBROOK AZ
86025-2218
US

IV. Provider business mailing address

2200 E SHOW LOW LAKE RD
SHOW LOW AZ
85901-7831
US

V. Phone/Fax

Practice location:
  • Phone: 928-524-2020
  • Fax: 928-524-3755
Mailing address:
  • Phone: 928-537-6393
  • Fax: 928-532-2131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KENNETH ROBERT ALLEN
Title or Position: CHIEF PRACTICE OFFICER
Credential:
Phone: 928-537-4375