Provider Demographics
NPI:1578623708
Name:EDISTO REGIONAL HEALTH SERVICES
Entity Type:Organization
Organization Name:EDISTO REGIONAL HEALTH SERVICES
Other - Org Name:
Other - Org Type:
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:
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 1:215 DORANGE RD
Practice Address - Street 2:
Practice Address - City:BRANCHVILLE
Practice Address - State:SC
Practice Address - Zip Code:29432-2241
Practice Address - Country:US
Practice Address - Phone:803-274-8400
Practice Address - Fax:803-274-8817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7265207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4574Medicaid
SC5677Medicare PIN