Provider Demographics
NPI:1134291214
Name:SUMMIT DERMATOLOGY LLC
Entity Type:Organization
Organization Name:SUMMIT DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:V
Authorized Official - Last Name:NOTARI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-616-7117
Mailing Address - Street 1:33 OVERLOOK RD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:SUMMIT
Mailing Address - State:NJ
Mailing Address - Zip Code:07901-3570
Mailing Address - Country:US
Mailing Address - Phone:908-598-7200
Mailing Address - Fax:908-598-7211
Practice Address - Street 1:33 OVERLOOK RD
Practice Address - Street 2:SUITE 209
Practice Address - City:SUMMIT
Practice Address - State:NJ
Practice Address - Zip Code:07901-3570
Practice Address - Country:US
Practice Address - Phone:908-598-7200
Practice Address - Fax:908-598-7211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA62000207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJG02290Medicare UPIN
NJ02287Medicare ID - Type UnspecifiedGROUP NUMBER