Healthcare Provider Details

I. General information

NPI: 1942701693
Provider Name (Legal Business Name): SUMMIT HEALTHCARE MEDICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2018
Last Update Date: 12/09/2019
Certification Date: 12/09/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4951 S WHITE MOUNTAIN RD BLDG A
SHOW LOW AZ
85901-7801
US

IV. Provider business mailing address

PO BOX 3050
SHOW LOW AZ
85902-3050
US

V. Phone/Fax

Practice location:
  • Phone: 289-537-6700
  • Fax: 928-532-2159
Mailing address:
  • Phone: 928-537-6393
  • Fax: 928-537-6725

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