Provider Demographics
NPI:1639475429
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:LIZA
Authorized Official - Middle Name:M
Authorized Official - Last Name:PORTERFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-395-4458
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:803-395-4762
Mailing Address - Fax:803-536-0998
Practice Address - Street 1:1619 CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-4939
Practice Address - Country:US
Practice Address - Phone:803-531-7474
Practice Address - Fax:803-531-7457
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EDISTO REGIONAL HEALTH SERVICES INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-01-27
Last Update Date:2020-02-26
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
SC018OtherBCBS
SC018OtherBLUECHOICE
SC016OtherTRICARE
SCGP5343Medicaid
SCCK8831OtherRRMEDICARE
SCRHC217Medicaid
SCCN8991OtherRRMEDICARE
SC5677Medicare PIN