Healthcare Provider Details

I. General information

NPI: 1285343871
Provider Name (Legal Business Name): SUMMIT MEDICAL CAROLINAS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2022
Last Update Date: 04/03/2024
Certification Date: 04/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

885 GOLD HILL RD # 253
FORT MILL SC
29708-7946
US

IV. Provider business mailing address

9250 E COSTILLA AVE STE 540
GREENWOOD VILLAGE CO
80112-3648
US

V. Phone/Fax

Practice location:
  • Phone: 720-644-9355
  • Fax:
Mailing address:
  • Phone: 720-644-9355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: RAJENDRA KADARI
Title or Position: MEMBER/MANAGER
Credential: M.D.
Phone: 720-644-9355