Healthcare Provider Details

I. General information

NPI: 1154875755
Provider Name (Legal Business Name): SUMMIT CLINICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2016
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 S MAIN ST #167
YARDLEY PA
19067-1527
US

IV. Provider business mailing address

25 S MAIN ST #167
YARDLEY PA
19067-1527
US

V. Phone/Fax

Practice location:
  • Phone: 718-382-0012
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. STUART H DITCHEK
Title or Position: CEO
Credential: M.D.
Phone: 718-382-0012