Healthcare Provider Details

I. General information

NPI: 1407466477
Provider Name (Legal Business Name): SUMMIT BRAIN HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2020
Last Update Date: 12/05/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1762 TECHNOLOGY DR STE 116
SAN JOSE CA
95110-1307
US

IV. Provider business mailing address

1762 TECHNOLOGY DR STE 116
SAN JOSE CA
95110-1307
US

V. Phone/Fax

Practice location:
  • Phone: 650-398-6329
  • Fax:
Mailing address:
  • Phone: 650-398-6329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. THOMAS ALAN GERACI
Title or Position: CREDENTIALING MANAGER
Credential: DO
Phone: 650-398-6329