1437271681 NPI number — SUMMER RIVER INC COMPLETE MEDICAL

Table of content: (NPI 1437271681)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437271681 NPI number — SUMMER RIVER INC COMPLETE MEDICAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUMMER RIVER INC COMPLETE MEDICAL
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1437271681
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20419 12TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKAWAY POINT
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11697-1120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-945-9119
Provider Business Mailing Address Fax Number:
718-945-6034

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
90-09 ROCKAWAY BEACH BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKAWAY BEACH
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11693-1531
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-945-9119
Provider Business Practice Location Address Fax Number:
718-945-6034
Provider Enumeration Date:
04/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FLANAGAN
Authorized Official First Name:
ED
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
917-363-3460

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 206175300 . This is a "DOL" identifier . This identifiers is of the category "OTHER".




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