Basic Information
| Provider Information | |||||||||
| NPI: | 1205023280 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUMMIT AMBULATORY SURGICAL CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14201 DALLAS PKWY STE 306 | ||||||||
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| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752542916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4698724706 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3407 WILKENS AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212295072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106440929 | ||||||||
| FaxNumber: | 4106444338 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2007 | ||||||||
| LastUpdateDate: | 08/17/2022 | ||||||||
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| AuthorizedOfficialLastName: | EASON | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICER/AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 4102539908 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/17/2022 | ||||||||
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 | 800906603 | 05 | MD | MEDICAID |