1093707416 NPI number — SUMMERTON FAMILY MEDICINE LLC

Table of content: (NPI 1093707416)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093707416 NPI number — SUMMERTON FAMILY MEDICINE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUMMERTON FAMILY MEDICINE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1093707416
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUMMERTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29148-0010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-485-2351
Provider Business Mailing Address Fax Number:
803-485-2219

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
107 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUMMERTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29148
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-485-2351
Provider Business Practice Location Address Fax Number:
803-485-2219
Provider Enumeration Date:
08/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
KOON
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
T.
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
803-485-2351

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: F891927161 . This is a "MEDICARE PROVIDER" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: GP3257 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: CJ8906 . This is a "MEDICARE ID RETIRED RR" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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