Provider Demographics
NPI:1093707416
Name:SUMMERTON FAMILY MEDICINE LLC
Entity Type:Organization
Organization Name:SUMMERTON FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:T
Authorized Official - Last Name:KOON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-485-2351
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:SUMMERTON
Mailing Address - State:SC
Mailing Address - Zip Code:29148-0010
Mailing Address - Country:US
Mailing Address - Phone:803-485-2351
Mailing Address - Fax:803-485-2219
Practice Address - Street 1:107 MAIN STREET
Practice Address - Street 2:
Practice Address - City:SUMMERTON
Practice Address - State:SC
Practice Address - Zip Code:29148
Practice Address - Country:US
Practice Address - Phone:803-485-2351
Practice Address - Fax:803-485-2219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-22
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCF891927161OtherMEDICARE PROVIDER
SCGP3257Medicaid
SCCJ8906OtherMEDICARE ID RETIRED RR
SC=========OtherBCBS
SC=========OtherAETNA
SC=========OtherTRICARE
SC=========OtherCOMPANION
SCGP3257Medicaid
SCGP3257Medicaid
SC=========OtherTRICARE