Provider Demographics
NPI:1275839078
Name:EDISTO REGIONAL HEALTH SERVICES INC
Entity Type:Organization
Organization Name:EDISTO REGIONAL HEALTH SERVICES INC
Other - Org Name:RMC PRIMARY CARE DENMARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:C F O
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:S
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-395-2224
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:803-395-4762
Mailing Address - Fax:803-395-2237
Practice Address - Street 1:5073 CAROLINA HWY
Practice Address - Street 2:
Practice Address - City:DENMARK
Practice Address - State:SC
Practice Address - Zip Code:29042-1679
Practice Address - Country:US
Practice Address - Phone:803-793-3034
Practice Address - Fax:803-245-6277
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EDISTO REGIONAL HEALTH SERVICES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-01-27
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
SC261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC020OtherBCBS
SCCK8831OtherRRMEDICARE
SCCN8991OtherRRMEDICARE
SCGP5405Medicaid
SC018OtherTRICARE
SC020OtherBLUECHOICE
SCCK8831OtherRRMEDICARE