Provider Demographics
NPI:1578603056
Name:SUMMERVILLE INTERNAL MEDICINE
Entity Type:Organization
Organization Name:SUMMERVILLE INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-875-6541
Mailing Address - Street 1:1710 OLD TROLLEY RD STE C
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485-8281
Mailing Address - Country:US
Mailing Address - Phone:843-875-6541
Mailing Address - Fax:843-875-5106
Practice Address - Street 1:1710 OLD TROLLEY RD STE C
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-8281
Practice Address - Country:US
Practice Address - Phone:843-875-6541
Practice Address - Fax:843-875-5106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15583207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC=========OtherTIN #