1811009137 NPI number — SUMMIT BREAST CARE, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811009137 NPI number — SUMMIT BREAST CARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUMMIT BREAST CARE, LLC
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:
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:
1811009137
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/07/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
98 FORD RD
Provider Second Line Business Mailing Address:
SUITE 3-H
Provider Business Mailing Address City Name:
DENVILLE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07834-1356
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-625-3366
Provider Business Mailing Address Fax Number:
973-625-0349

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
89 SPARTA AVE
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
SPARTA
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07871-1777
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-729-6517
Provider Business Practice Location Address Fax Number:
973-729-3194
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
O'SHEA
Authorized Official First Name:
MICHELLE
Authorized Official Middle Name:
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
973-670-4244

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  25MA04336800 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8767700 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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