Basic Information
| Provider Information | |||||||||
| NPI: | 1922061092 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUMMIT COSMETIC SURGERY CENTER,PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1717 SHIPYARD BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284038019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107945355 | ||||||||
| FaxNumber: | 9107945358 | ||||||||
| Practice Location | |||||||||
| Address1: | 1717 SHIPYARD BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284038019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107945355 | ||||||||
| FaxNumber: | 9107945358 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2006 | ||||||||
| LastUpdateDate: | 01/04/2011 | ||||||||
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| AuthorizedOfficialLastName: | RICCIARDELLI | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9107945355 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.