Provider Demographics
NPI:1396976700
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:REVENUE INTEGRITY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTAL
Authorized Official - Middle Name:LEANN
Authorized Official - Last Name:FULMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-395-4248
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:
Practice Address - Street 1:651A HARRY C RAYSOR DR
Practice Address - Street 2:
Practice Address - City:ST MATTHEWS
Practice Address - State:SC
Practice Address - Zip Code:29135-1487
Practice Address - Country:US
Practice Address - Phone:803-395-3755
Practice Address - Fax:803-874-3905
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EDISTO REGIONAL HEALTH SERVICES INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-08-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
SC261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCN8991OtherRRMEDICARE
SCGP5396Medicaid
SC017OtherBCBS
SC015OtherBLUECHOICE
SC015OtherTRICARE
SCCK8831OtherRRMEDICARE
SC5677Medicare PIN
SC015OtherBLUECHOICE
SC428907Medicare PIN