Healthcare Provider Details

I. General information

NPI: 1093284408
Provider Name (Legal Business Name): SUMMIT HEALTHCARE IPA CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2018
Last Update Date: 11/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23049 ARCHIBALD AVE
CARSON CA
90745-4718
US

IV. Provider business mailing address

6119 E WASHINGTON BLVD
COMMERCE CA
90040-2436
US

V. Phone/Fax

Practice location:
  • Phone: 310-850-5630
  • Fax: 888-444-9401
Mailing address:
  • Phone: 888-350-6599
  • Fax: 888-444-9401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MARK N SAMONTE
Title or Position: CEO
Credential: MD
Phone: 310-850-5630