Healthcare Provider Details

I. General information

NPI: 1164788261
Provider Name (Legal Business Name): SUMMIT MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2012
Last Update Date: 04/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 THOMAS MORE PKWY SU. 160A
CRESTVIEW HILLS KY
41017-5100
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 859-334-6466
  • Fax: 859-344-7930
Mailing address:
  • Phone: 859-344-5555
  • Fax: 859-344-5552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: GLENN LOOMIS
Title or Position: PRESIDENT/CEO
Credential:
Phone: 859-344-3733