Basic Information
Provider Information | |||||||||
NPI: | 1568061315 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SUMMIT MEDICAL GROUP PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CITYMD URGENT CARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1 DIAMOND HILL RD | ||||||||
Address2: |   | ||||||||
City: | BERKELEY HEIGHTS | ||||||||
State: | NJ | ||||||||
PostalCode: | 079222104 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9082734300 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 970 HOOPER AVE # 2 | ||||||||
Address2: |   | ||||||||
City: | TOMS RIVER | ||||||||
State: | NJ | ||||||||
PostalCode: | 087538319 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7322284146 | ||||||||
FaxNumber: | 7325047104 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/22/2020 | ||||||||
LastUpdateDate: | 06/25/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SAUNDERS | ||||||||
AuthorizedOfficialFirstName: | PETER | ||||||||
AuthorizedOfficialMiddleName: | T | ||||||||
AuthorizedOfficialTitleorPosition: | VP REVENUE CYCLE | ||||||||
AuthorizedOfficialTelephone: | 9085883930 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SUMMIT MEDICAL GROUP PA | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/25/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.