Healthcare Provider Details

I. General information

NPI: 1235275207
Provider Name (Legal Business Name): SUMMIT MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HIGHLAND AVE STE 307
PROVIDENCE RI
02906-2753
US

IV. Provider business mailing address

100 HIGHLAND AVE STE 307
PROVIDENCE RI
02906-2753
US

V. Phone/Fax

Practice location:
  • Phone: 401-331-5320
  • Fax: 401-331-6168
Mailing address:
  • Phone: 401-331-5320
  • Fax: 401-331-6168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberRI3593
License Number StateRI

VIII. Authorized Official

Name: MARVIN STUART KERZNER
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 401-331-5320