Provider Demographics
NPI:1811040322
Name:EDISTO ORTHOPAEDICS, PA
Entity Type:Organization
Organization Name:EDISTO ORTHOPAEDICS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:HOLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-782-4141
Mailing Address - Street 1:302 MEDICAL PARK DR
Mailing Address - Street 2:SUITE 111
Mailing Address - City:WALTERBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29488-5747
Mailing Address - Country:US
Mailing Address - Phone:843-782-4141
Mailing Address - Fax:843-549-7967
Practice Address - Street 1:302 MEDICAL PARK DR
Practice Address - Street 2:SUITE 111
Practice Address - City:WALTERBORO
Practice Address - State:SC
Practice Address - Zip Code:29488-5747
Practice Address - Country:US
Practice Address - Phone:843-782-4141
Practice Address - Fax:843-549-7967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2610Medicaid
SCGP2610Medicaid