Provider Demographics
NPI:1043404650
Name:PSI SUMMIT PROFESSIONAL GROUP
Entity Type:Organization
Organization Name:PSI SUMMIT PROFESSIONAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:PAT
Authorized Official - Middle Name:
Authorized Official - Last Name:HOFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-778-1242
Mailing Address - Street 1:19 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:NJ
Mailing Address - Zip Code:07901-2530
Mailing Address - Country:US
Mailing Address - Phone:800-753-5223
Mailing Address - Fax:
Practice Address - Street 1:19 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:NJ
Practice Address - Zip Code:07901-2530
Practice Address - Country:US
Practice Address - Phone:800-753-5223
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PSI SUMMIT HOSPITAL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-28
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========UOtherHORIZON BLUE CROSS