MEDICARE: SUMMERTON FAMILY MEDICINE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	F891927161	OTHER	SC	MEDICARE PROVIDER
3	CJ8906	OTHER	SC	MEDICARE ID RETIRED RR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093707416
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUMMERTON FAMILY MEDICINE LLC

Provider Business Mailing Address
First Line	:	PO BOX 10
Second Line	:
City	:	SUMMERTON
State	:	SC
Zip	:	29148-0010
Country	:	US
Telephone Number	:	803-485-2351
Fax Number	:	803-485-2219

Provider Business Practice Location Address
First Line	:	107 MAIN STREET
Second Line	:
City	:	SUMMERTON
State	:	SC
Zip	:	29148
Country	:	US
Telephone Number	:	803-485-2351
Fax Number	:	803-485-2219

Authorized Official
Title or Position	:	OWNER/PHYSICIAN
Name	:	DR. DAVID T. KOON
Credential	:	MD
Telephone Number	:	803-485-2351

Provider Enumeration Date	:	08/22/2005
Last Update Date	:	05/08/2008

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Directions to “SUMMERTON FAMILY MEDICINE LLC ” Practice Location

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