Provider Demographics
NPI:1417110032
Name:EDGEFIELD COUNTY HOSPITAL
Entity Type:Organization
Organization Name:EDGEFIELD COUNTY HOSPITAL
Other - Org Name:PEACH TREE MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:W
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-637-3630
Mailing Address - Street 1:155 RIDGE MEDICAL PLAZA
Mailing Address - Street 2:SUITE B
Mailing Address - City:EDGEFIELD
Mailing Address - State:SC
Mailing Address - Zip Code:29824-4535
Mailing Address - Country:US
Mailing Address - Phone:803-637-3630
Mailing Address - Fax:803-637-5348
Practice Address - Street 1:155 RIDGE MEDICAL PLAZA
Practice Address - Street 2:SUITE B
Practice Address - City:EGEFIELD
Practice Address - State:SC
Practice Address - Zip Code:29824-4535
Practice Address - Country:US
Practice Address - Phone:803-637-3630
Practice Address - Fax:803-637-5348
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EDGEFIELD COUNTY HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-03
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCHTL479261QR1300X, 282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCRHC548Medicaid
SCRHC548Medicaid