Provider Demographics
NPI:1033200704
Name:SUMMIT PLASTIC SURGERY, PC
Entity Type:Organization
Organization Name:SUMMIT PLASTIC SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:N
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:908-918-1969
Mailing Address - Street 1:33 OVERLOOK RD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:SUMMIT
Mailing Address - State:NJ
Mailing Address - Zip Code:07901-3563
Mailing Address - Country:US
Mailing Address - Phone:908-918-1969
Mailing Address - Fax:908-918-1995
Practice Address - Street 1:33 OVERLOOK RD
Practice Address - Street 2:SUITE 310
Practice Address - City:SUMMIT
Practice Address - State:NJ
Practice Address - Zip Code:07901-3563
Practice Address - Country:US
Practice Address - Phone:908-918-1969
Practice Address - Fax:908-918-1995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA053736002086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJF77503Medicare UPIN
NJ764314Medicare ID - Type Unspecified