Provider Demographics
NPI:1982650107
Name:EDISTO REGIONAL HEALTH SERVICES
Entity Type:Organization
Organization Name:EDISTO REGIONAL HEALTH SERVICES
Other - Org Name:EDISTO REGIONAL PEDIATRICS
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 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:803-536-0998
Practice Address - Street 1:2850 PELHAM CT
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-1400
Practice Address - Country:US
Practice Address - Phone:803-531-8500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4354Medicaid
SC=========008OtherBCBS GROUP#
SC5677Medicare ID - Type Unspecified