=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497579288
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUMMIT ANESTHESIA GROUP, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2024
-----------------------------------------------------
Last Update Date | 11/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 959 SUNLAND PARK DR STE 200
-----------------------------------------------------
City | EL PASO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79922-1323
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-235-5564
-----------------------------------------------------
Fax | 915-542-0156
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 959 SUNLAND PARK DR STE 200
-----------------------------------------------------
City | EL PASO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79922-1323
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-235-5564
-----------------------------------------------------
Fax | 915-542-0156
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MARK GALLARDO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 915-235-5564
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------