Provider Demographics
NPI:1174578058
Name:SUMMIT PHYSICAL THERAPY, PLLC
Entity type:Organization
Organization Name:SUMMIT PHYSICAL THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:A
Authorized Official - Last Name:GOUMAS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:859-737-3994
Mailing Address - Street 1:126 PROFESSIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40391-1116
Mailing Address - Country:US
Mailing Address - Phone:859-737-3994
Mailing Address - Fax:859-737-3223
Practice Address - Street 1:126 PROFESSIONAL AVE
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40391-1116
Practice Address - Country:US
Practice Address - Phone:859-737-3994
Practice Address - Fax:859-737-3223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY87900643Medicaid
KY7383Medicare ID - Type Unspecified