=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396769790
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUMMIT FAMILY MEDICINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29 SOUTH ST FLOOR 1
-----------------------------------------------------
City | NEW PROVIDENCE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07974-1940
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-464-4200
-----------------------------------------------------
Fax | 908-464-1332
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29 SOUTH ST FLOOR 1
-----------------------------------------------------
City | NEW PROVIDENCE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07974-1940
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-464-4200
-----------------------------------------------------
Fax | 908-464-1332
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | NANCY STOLL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 908-464-4200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 25MA07833500
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------