Provider Demographics
NPI:1013060953
Name:EDISTO REGIONAL HEALTH SERVICES, INC.
Entity type:Organization
Organization Name:EDISTO REGIONAL HEALTH SERVICES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:C.F.O.
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:S
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-395-2224
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:803-395-2237
Practice Address - Street 1:187 BUNCH FORD ROAD
Practice Address - Street 2:
Practice Address - City:HOLLY HILL
Practice Address - State:SC
Practice Address - Zip Code:29059-8224
Practice Address - Country:US
Practice Address - Phone:803-496-3312
Practice Address - Fax:803-496-7713
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EDISTO REGIONAL HEALTH SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-22
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCK8831OtherRRMEDICARE
SCCN8991OtherRRMEDICARE
SCRHC012Medicaid
SCGP2353Medicaid
SC004OtherBCBS
SC003OtherTRICARE
SC004OtherBLUECHOICE
SCRHC012Medicaid
SC003OtherTRICARE