Provider Demographics
NPI:1598717910
Name:SUMMERVILLE FOOTCARE CENTER, PA
Entity Type:Organization
Organization Name:SUMMERVILLE FOOTCARE CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:IMKO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:843-871-0100
Mailing Address - Street 1:105 N CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-6401
Mailing Address - Country:US
Mailing Address - Phone:843-871-0100
Mailing Address - Fax:843-871-0104
Practice Address - Street 1:105 N CEDAR ST
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-6401
Practice Address - Country:US
Practice Address - Phone:843-871-0100
Practice Address - Fax:843-871-0104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC53261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT25026Medicare UPIN
SCT250260282Medicare ID - Type Unspecified
SC0329070001Medicare NSC