Healthcare Provider Details

I. General information

NPI: 1902099500
Provider Name (Legal Business Name): SUMMIT SKIN CARE INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2007
Last Update Date: 09/16/2022
Certification Date: 09/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3521 NE RALPH POWELL RD STE C
LEES SUMMIT MO
64064-2324
US

IV. Provider business mailing address

3521 NE RALPH POWELL RD STE C
LEES SUMMIT MO
64064-2324
US

V. Phone/Fax

Practice location:
  • Phone: 816-554-8346
  • Fax: 816-554-9470
Mailing address:
  • Phone: 816-554-8346
  • Fax: 816-554-9470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number102868
License Number StateMO

VIII. Authorized Official

Name: BRUCE E FEARON
Title or Position: OWNER / PRESIDENT
Credential: MD
Phone: 816-554-7546