Provider Demographics
NPI:1740725100
Name:SUMMERTON PRIMARY CARE
Entity type:Organization
Organization Name:SUMMERTON PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ANP
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:S
Authorized Official - Last Name:BARWICK
Authorized Official - Suffix:
Authorized Official - Credentials:ANP
Authorized Official - Phone:803-488-8888
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:123 MAIN ST
Mailing Address - City:SUMMERTON
Mailing Address - State:SC
Mailing Address - Zip Code:29148-0069
Mailing Address - Country:US
Mailing Address - Phone:803-488-8888
Mailing Address - Fax:803-488-0111
Practice Address - Street 1:123 MAIN ST
Practice Address - Street 2:
Practice Address - City:SUMMERTON
Practice Address - State:SC
Practice Address - Zip Code:29148
Practice Address - Country:US
Practice Address - Phone:803-488-8888
Practice Address - Fax:803-488-0111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-21
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN174363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP7622Medicaid
SCGP7622Medicaid