1093792608 NPI number — DR. JAMES FLETCHER KOON MD

Table of content: (NPI 1851389035)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093792608 NPI number — DR. JAMES FLETCHER KOON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOON
Provider First Name:
JAMES
Provider Middle Name:
FLETCHER
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093792608
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
206 S MATSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KERSHAW
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29067-1506
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-475-1156
Provider Business Mailing Address Fax Number:
803-475-1128

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
206 S MATSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KERSHAW
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29067-1506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-475-1156
Provider Business Practice Location Address Fax Number:
803-475-1128
Provider Enumeration Date:
12/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  18339 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 080179118 . This is a "RETIRED RR MEDICARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 000000229650 . This is a "UNISON" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 5532095 . This is a "AETNA" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 8874326 . This is a "PPNI" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: T24079 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01153584 . This is a "AMERIGROUP" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 20071782 . This is a "SELECT HEALTH" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 21149333031 . This is a "BEECHSTREET" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: A8973 . This is a "MEDCOST" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 3091345 . This is a "CIGNA" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 0141069 . This is a "CAROLINA CARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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