Healthcare Provider Details

I. General information

NPI: 1154322410
Provider Name (Legal Business Name): SUMMIT SURGICAL SUITES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7920 W JEFFERSON BLVD SUITE 210
FORT WAYNE IN
46804-4168
US

IV. Provider business mailing address

7920 W JEFFERSON BLVD SUITE 210
FORT WAYNE IN
46804-4168
US

V. Phone/Fax

Practice location:
  • Phone: 260-434-2022
  • Fax: 260-434-2023
Mailing address:
  • Phone: 260-434-2022
  • Fax: 260-434-2023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number05-003212-1
License Number StateIN

VIII. Authorized Official

Name: KRISTY MUSIC
Title or Position: DIRECTOR OF PROVIDER ENROLLMENT-AO
Credential:
Phone: 615-465-7377