Healthcare Provider Details

I. General information

NPI: 1346515491
Provider Name (Legal Business Name): SUMMIT MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2012
Last Update Date: 03/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 BRIDGEWAY ST
AURORA IN
47001-1334
US

IV. Provider business mailing address

2300 CHAMBER CENTER DR SU. 200
LAKESIDE PARK KY
41017-1673
US

V. Phone/Fax

Practice location:
  • Phone: 812-926-3133
  • Fax: 812-926-1668
Mailing address:
  • Phone: 859-344-5555
  • Fax: 859-344-5552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: GLENN LOOMIS
Title or Position: PRESIDEN, CEO
Credential:
Phone: 859-344-3733