Provider Demographics
NPI:1598080079
Name:EDISTO REGIONAL HEALTH SERVICES INC.
Entity Type:Organization
Organization Name:EDISTO REGIONAL HEALTH SERVICES INC.
Other - Org Name:WILLIAM D. GLENN IV MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:C.O.O.
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GOODLETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-395-2462
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:803-395-4497
Mailing Address - Fax:803-536-0998
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:803-245-5144
Practice Address - Fax:803-245-6277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-29
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19072207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC5677Medicare PIN