Provider Demographics
NPI:1346607066
Name:SUMMIT COSMETIC SURGERY CENTER
Entity Type:Organization
Organization Name:SUMMIT COSMETIC SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:NORIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-794-5355
Mailing Address - Street 1:1717 SHIPYARD BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-8023
Mailing Address - Country:US
Mailing Address - Phone:910-794-5355
Mailing Address - Fax:910-794-5358
Practice Address - Street 1:1717 SHIPYARD BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-8023
Practice Address - Country:US
Practice Address - Phone:910-794-5355
Practice Address - Fax:910-794-5358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-26
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9600699174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCCH0945OtherRAILROAD MEDICARE PTAN
NC2344578OtherPTAN
NC89016GKMedicaid
NC2344578OtherPTAN
NCF68078Medicare UPIN