Provider Demographics
NPI:1972541811
Name:SUMMIT MEDICAL GROUP (ABDOU & BACCHUS) PC
Entity type:Organization
Organization Name:SUMMIT MEDICAL GROUP (ABDOU & BACCHUS) PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MALISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:THATCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-932-8547
Mailing Address - Street 1:525 N 18TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-4102
Mailing Address - Country:US
Mailing Address - Phone:702-932-8547
Mailing Address - Fax:702-932-8586
Practice Address - Street 1:1776 E WARM SPRINGS RD
Practice Address - Street 2:208
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-4676
Practice Address - Country:US
Practice Address - Phone:702-932-8547
Practice Address - Fax:702-932-8586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ=========OtherTAX ID
AZ=========OtherTAX ID