Provider Demographics
NPI:1679865109
Name:321 SUMMIT MEDICAL
Entity Type:Organization
Organization Name:321 SUMMIT MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:S
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-343-2434
Mailing Address - Street 1:321 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-1429
Mailing Address - Country:US
Mailing Address - Phone:201-343-2434
Mailing Address - Fax:201-343-3917
Practice Address - Street 1:321 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1429
Practice Address - Country:US
Practice Address - Phone:201-343-2434
Practice Address - Fax:201-343-3917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-03
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty