Basic Information
| Provider Information | |||||||||
| NPI: | 1144467804 | ||||||||
| 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: | 7625 MAPLE LAWN BLVD | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | FULTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207592565 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4437382872 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2009 | ||||||||
| LastUpdateDate: | 08/26/2011 | ||||||||
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| AuthorizedOfficialLastName: | SIEGEL | ||||||||
| AuthorizedOfficialFirstName: | SANFORD | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4437382872 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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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 | 800906616 | 05 | MD | MEDICAID |