Provider Demographics
NPI:1639117732
Name:EDISTO REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:EDISTO REGIONAL MEDICAL CENTER
Other - Org Name:RACHAEL E GROSS, DO
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:
Authorized Official - Credentials:
Authorized Official - Phone:803-395-2200
Mailing Address - Street 1:PO BOX 1442
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29116-1442
Mailing Address - Country:US
Mailing Address - Phone:803-395-4499
Mailing Address - Fax:803-395-4480
Practice Address - Street 1:1727 VILLAGE PARK DR
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-2475
Practice Address - Country:US
Practice Address - Phone:803-531-2722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4305Medicaid
SCGP4305Medicaid
SCGP4305Medicaid