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General NPI Number Information
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NPI Number | 1154322410
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Entity Type | Organization
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Legal Business Name | SUMMIT SURGICAL SUITES, LLC
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Dates
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Enumeration Date | 08/09/2005
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Last Update Date | 08/12/2024
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Provider Practice Location Address
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Address Line | 7920 W JEFFERSON BLVD SUITE 210
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City | FORT WAYNE
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State | IN
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Zip | 46804-4168
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Country | US
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Telephone | 260-434-2022
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Fax | 260-434-2023
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Provider Business Mailing Address
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Address Line | 7920 W JEFFERSON BLVD SUITE 210
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City | FORT WAYNE
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State | IN
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Zip | 46804-4168
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Country | US
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Telephone | 260-434-2022
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Fax | 260-434-2023
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Authorized Official
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Title or Position | DIRECTOR OF PROVIDER ENROLLMENT-AO
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Name | KRISTY MUSIC
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Credential |
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Telephone | 615-465-7377
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 05-003212-1
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License Number State | IN
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