Provider Demographics
NPI:1023098712
Name:HEDGEMARK BRENTWOOD MEDICAL SERVICES, INC.-DBA PHC HOME HEALTH
Entity type:Organization
Organization Name:HEDGEMARK BRENTWOOD MEDICAL SERVICES, INC.-DBA PHC HOME HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:V-PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:S
Authorized Official - Last Name:DURRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:843-762-3601
Mailing Address - Street 1:1548 ASHLEY RIVER ROAD SUITE B
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407
Mailing Address - Country:US
Mailing Address - Phone:843-762-3601
Mailing Address - Fax:843-762-7074
Practice Address - Street 1:408 FOLLY ROAD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412
Practice Address - Country:US
Practice Address - Phone:843-762-3601
Practice Address - Fax:843-762-7074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-19
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCHHA-084251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC470555Medicaid
SC=========OtherTIN # FOR PRIVATE INSUR.
SC42-7055Medicare PIN
SC=========OtherTIN # FOR PRIVATE INSUR.