Basic Information
| Provider Information | |||||||||
| NPI: | 1003004482 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUMMIT AMBULATORY SURGICAL CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 CROSSROADS DR | ||||||||
| Address2: | SUITE 306 | ||||||||
| City: | OWINGS MILLS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211175421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4437382872 | ||||||||
| FaxNumber: | 4437382713 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 SISTER PIERRE DR | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | TOWSON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212047516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104941402 | ||||||||
| FaxNumber: | 4102968572 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2007 | ||||||||
| LastUpdateDate: | 08/31/2011 | ||||||||
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| AuthorizedOfficialLastName: | SIEGEL | ||||||||
| AuthorizedOfficialFirstName: | SANFORD | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4105811600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 800906600 | 05 | MD | MEDICAID |