Provider Demographics
NPI:1053538843
Name:SUMMIT MEDICAL SPECIALISTS, SC
Entity type:Organization
Organization Name:SUMMIT MEDICAL SPECIALISTS, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVENHAGEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-513-0700
Mailing Address - Street 1:2717 N GRANDVIEW BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-1660
Mailing Address - Country:US
Mailing Address - Phone:262-513-0700
Mailing Address - Fax:262-513-0707
Practice Address - Street 1:2717 N GRANDVIEW BLVD STE 202
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-1660
Practice Address - Country:US
Practice Address - Phone:262-513-0700
Practice Address - Fax:262-513-0707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI333982084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32189000Medicaid
WIG10532Medicare UPIN
WI32189000Medicaid