=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730900747
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUMMIT MEDICAL CENTER LABORATORY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2024
-----------------------------------------------------
Last Update Date | 10/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1800 RENAISSANCE BLVD
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73013-3023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-359-2482
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1800 RENAISSANCE BLVD
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73013-3023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-359-2482
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | GERON DAUGHERTY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 405-359-2482
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------