Healthcare Provider Details

I. General information

NPI: 1548677636
Provider Name (Legal Business Name): SUMMIT MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2014
Last Update Date: 07/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 ALEXANDRIA PIKE STE 230
SOUTHGATE KY
41071-3290
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 859-441-4334
  • Fax: 859-441-1368
Mailing address:
  • Phone: 859-344-5501
  • Fax: 859-795-5495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number
License Number StateKY

VIII. Authorized Official

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