Provider Demographics
NPI:1003130956
Name:EDISTO REGIONAL HEALTH SERVICES INC.
Entity Type:Organization
Organization Name:EDISTO REGIONAL HEALTH SERVICES INC.
Other - Org Name:RMC PRIMARY CARE BAMBERG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:C.F.O.
Authorized Official - Prefix:MS
Authorized Official - First Name:LIZA
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTERFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-395-4458
Mailing Address - Street 1:PO BOX 1245
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29116-1245
Mailing Address - Country:US
Mailing Address - Phone:803-395-4497
Mailing Address - Fax:803-395-2237
Practice Address - Street 1:498 NORTH STREET
Practice Address - Street 2:
Practice Address - City:BAMBERG
Practice Address - State:SC
Practice Address - Zip Code:29003-1377
Practice Address - Country:US
Practice Address - Phone:803-245-5144
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EDISTO REGIONAL HEALTH SERVICES INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-03-22
Last Update Date:2017-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19072207Q00000X, 261QR1300X
SC22299207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCN8991OtherRRMEDICARE
SC019OtherBLUECHOICE
SC017OtherTRICARE
SCGP5405Medicaid
SC019OtherBCBS
SCRHC199OtherMEDICARE RURAL HEALTH
SCCK8831OtherRRMEDICARE