Provider Demographics
NPI:1982048062
Name:SUMMERVILLE PRIMARY CARE
Entity Type:Organization
Organization Name:SUMMERVILLE PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAGEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-285-7820
Mailing Address - Street 1:299 MIDLAND PKWY # A
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485-8104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:299-A MIDLAND PARKWAY
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485
Practice Address - Country:US
Practice Address - Phone:985-413-9829
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-19
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8823207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCC453Medicare PIN