Organization
SUMMIT RADIOLOGY SERVICES LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
GLENN A TUCKMAN M.D. (PRESIDENT)
(765) 449-7984
Entity
Organization
Contact information
Practice address
3738 LANDMARK DR., SUITE D, LAFAYETTE, IN 47905-6655
(765) 449-7984
(765) 449-9791
Mailing address
3738 LANDMARK DR., SUITE D, LAFAYETTE, IN 47905-6655
(765) 449-7984
(765) 449-9791
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200020370B
—
IN
01
—
31714000
MEDICAID
WI
01
—
64882822
MEDICAID
KY
Enumeration date
07/15/2006
Last updated
01/25/2013
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