Provider Demographics
NPI:1396769790
Name:SUMMIT FAMILY MEDICINE
Entity type:Organization
Organization Name:SUMMIT FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:STOLL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:908-464-4200
Mailing Address - Street 1:29 SOUTH ST
Mailing Address - Street 2:FLOOR 1
Mailing Address - City:NEW PROVIDENCE
Mailing Address - State:NJ
Mailing Address - Zip Code:07974-1940
Mailing Address - Country:US
Mailing Address - Phone:908-464-4200
Mailing Address - Fax:908-464-1332
Practice Address - Street 1:29 SOUTH ST
Practice Address - Street 2:FLOOR 1
Practice Address - City:NEW PROVIDENCE
Practice Address - State:NJ
Practice Address - Zip Code:07974-1940
Practice Address - Country:US
Practice Address - Phone:908-464-4200
Practice Address - Fax:908-464-1332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07833500207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ149256Medicare UPIN
NJ098169Medicare ID - Type Unspecified