=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407959430
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUDITH MARIE SUMMERS RPA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 510 MONTAUK HIGHWAY SUITE C
-----------------------------------------------------
City | WEST ISLIP
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11795
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-587-1451
-----------------------------------------------------
Fax | 631-587-0503
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 57 N. OCEANSIDE ROAD
-----------------------------------------------------
City | ROCKVILLE CENTRE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-837-9864
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | 009084-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------