Provider Demographics
NPI:1477700516
Name:SUMMIT AMBULATORY SURGICAL CENTER LLC
Entity type:Organization
Organization Name:SUMMIT AMBULATORY SURGICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SANFORD
Authorized Official - Middle Name:J
Authorized Official - Last Name:SIEGEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:443-738-8163
Mailing Address - Street 1:25 CROSSROADS DRIVE
Mailing Address - Street 2:SUITE 306
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-4295
Mailing Address - Country:US
Mailing Address - Phone:443-738-2872
Mailing Address - Fax:443-738-2713
Practice Address - Street 1:251 LEWIS LANE
Practice Address - Street 2:SUITE 203
Practice Address - City:HAVRE DE GRACE
Practice Address - State:MD
Practice Address - Zip Code:21078-5421
Practice Address - Country:US
Practice Address - Phone:410-942-0130
Practice Address - Fax:410-939-3538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-20
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD800906615Medicaid
MD21C0001493Medicare Oscar/Certification
MD165807Medicare PIN