Provider Demographics
NPI:1144219726
Name:EDISTO MULTISPECIALTY ASSOCIATES INC
Entity Type:Organization
Organization Name:EDISTO MULTISPECIALTY ASSOCIATES INC
Other - Org Name:DBA EDISTO PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COORDINATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:ENGLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-661-3365
Mailing Address - Street 1:302 MEDICAL PARK DR
Mailing Address - Street 2:SUITE 211
Mailing Address - City:WALTERBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29488-5747
Mailing Address - Country:US
Mailing Address - Phone:843-549-0787
Mailing Address - Fax:843-549-6867
Practice Address - Street 1:302 MEDICAL PARK DR
Practice Address - Street 2:SUITE 211
Practice Address - City:WALTERBORO
Practice Address - State:SC
Practice Address - Zip Code:29488-5747
Practice Address - Country:US
Practice Address - Phone:843-549-0787
Practice Address - Fax:843-549-6867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-17
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCRHC508/GP3156Medicaid