Healthcare Provider Details

I. General information

NPI: 1750802807
Provider Name (Legal Business Name): CURTIS ELLSWORTH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2017
Last Update Date: 07/07/2022
Certification Date: 06/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SUMMIT HEALTHCARE ORTHOPEDIC SURGERY 4951 S WHITE MOUNTAIN RD, BLDG A
SHOW LOW AZ
85901
US

IV. Provider business mailing address

4951 S WHITE MOUNTAIN RD BLDG A
SHOW LOW AZ
85901-7827
US

V. Phone/Fax

Practice location:
  • Phone: 928-537-6700
  • Fax: 928-537-0033
Mailing address:
  • Phone: 928-537-6700
  • Fax: 928-537-0033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number2017019588
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number009627
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: