Provider Demographics
NPI:1063517084
Name:SUMMIT MEDICAL ASSOCIATES LLC
Entity type:Organization
Organization Name:SUMMIT MEDICAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BHAKTAVATSALA
Authorized Official - Middle Name:R
Authorized Official - Last Name:APURI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-434-1177
Mailing Address - Street 1:4656 W JEFFERSON BLVD
Mailing Address - Street 2:SUITE 125
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6857
Mailing Address - Country:US
Mailing Address - Phone:260-434-1177
Mailing Address - Fax:888-854-6745
Practice Address - Street 1:4656 W JEFFERSON BLVD
Practice Address - Street 2:SUITE 125
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6857
Practice Address - Country:US
Practice Address - Phone:260-434-1177
Practice Address - Fax:888-854-6745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200468080AMedicaid
IN215050Medicare PIN
INF63534Medicare UPIN