Provider Demographics
NPI:1285641332
Name:EDISTO REGIONAL HEALTH SERVICES
Entity Type:Organization
Organization Name:EDISTO REGIONAL HEALTH SERVICES
Other - Org Name:COPELAND MEDICAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:DANDRIDGE
Authorized Official - Suffix:I
Authorized Official - Credentials:
Authorized Official - Phone:803-395-2200
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:803-395-4499
Mailing Address - Fax:803-395-4480
Practice Address - Street 1:2850 PELHAM CT
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-1400
Practice Address - Country:US
Practice Address - Phone:803-655-6132
Practice Address - Fax:803-655-6173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN652207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3748Medicaid
SC5677Medicare PIN