Healthcare Provider Details

I. General information

NPI: 1598717910
Provider Name (Legal Business Name): SUMMERVILLE FOOTCARE CENTER, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 07/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 N CEDAR ST
SUMMERVILLE SC
29483-6401
US

IV. Provider business mailing address

105 N CEDAR ST
SUMMERVILLE SC
29483-6401
US

V. Phone/Fax

Practice location:
  • Phone: 843-871-0100
  • Fax: 843-871-0104
Mailing address:
  • Phone: 843-871-0100
  • Fax: 843-871-0104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number53
License Number StateSC

VIII. Authorized Official

Name: DR. EDWARD A IMKO
Title or Position: PRACTITIONER
Credential: DPM
Phone: 843-871-0100