Provider Demographics
NPI:1093371742
Name:EAST SUMMIT MEDICAL PC
Entity Type:Organization
Organization Name:EAST SUMMIT MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:TIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-336-8422
Mailing Address - Street 1:7116 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:MASPETH
Mailing Address - State:NY
Mailing Address - Zip Code:11378-1823
Mailing Address - Country:US
Mailing Address - Phone:646-609-6138
Mailing Address - Fax:
Practice Address - Street 1:40 BOWERY # GROUND
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-4801
Practice Address - Country:US
Practice Address - Phone:646-609-6138
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-17
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty