Healthcare Provider Details

I. General information

NPI: 1275531550
Provider Name (Legal Business Name): SUMMIT AVENUE MEDICAL PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 SUMMIT AVE STE 1
HACKENSACK NJ
07601-8503
US

IV. Provider business mailing address

5 SUMMIT AVE STE 1
HACKENSACK NJ
07601-8503
US

V. Phone/Fax

Practice location:
  • Phone: 201-646-0001
  • Fax: 201-646-9101
Mailing address:
  • Phone: 201-646-0001
  • Fax: 201-646-9101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0127584001
Identifier TypeOTHER
Identifier State
Identifier IssuerAMERIHEALTH
# 2
Identifier2514
Identifier TypeOTHER
Identifier State
Identifier IssuerAETNA US HEALTHCARE
# 3
IdentifierCD1762
Identifier TypeOTHER
Identifier State
Identifier IssuerRAILROAD MEDICARE

VIII. Authorized Official

Name: MRS. SHARON B LEVONT
Title or Position: OFFICE MANAGER
Credential:
Phone: 201-646-0001