Provider Demographics
NPI:1194701664
Name:SUMMIT PLASTIC SURGERY, PC
Entity type:Organization
Organization Name:SUMMIT PLASTIC SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:FIECHTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-490-7111
Mailing Address - Street 1:7920 W JEFFERSON BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4166
Mailing Address - Country:US
Mailing Address - Phone:260-490-7111
Mailing Address - Fax:260-490-2286
Practice Address - Street 1:7920 W JEFFERSON BLVD STE 200
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4166
Practice Address - Country:US
Practice Address - Phone:260-490-7111
Practice Address - Fax:260-490-2286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-16
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2289394Medicaid
IN200375290AMedicaid
OH2289394Medicaid
IN186080Medicare PIN
IN186080Medicare PIN