Healthcare Provider Details

I. General information

NPI: 1053538843
Provider Name (Legal Business Name): SUMMIT MEDICAL SPECIALISTS, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2717 N GRANDVIEW BLVD STE 202
WAUKESHA WI
53188-1660
US

IV. Provider business mailing address

2717 N GRANDVIEW BLVD STE 202
WAUKESHA WI
53188-1660
US

V. Phone/Fax

Practice location:
  • Phone: 262-513-0700
  • Fax: 262-513-0707
Mailing address:
  • Phone: 262-513-0700
  • Fax: 262-513-0707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number33398
License Number StateWI

VIII. Authorized Official

Name: TIM LEVENHAGEN
Title or Position: OWNER
Credential: MD
Phone: 262-513-0700