Provider Demographics
NPI:1841595667
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:
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 1:4631 SAVANNAH HIGHWAY
Practice Address - Street 2:
Practice Address - City:NORTH
Practice Address - State:SC
Practice Address - Zip Code:29112-8180
Practice Address - Country:US
Practice Address - Phone:803-247-2428
Practice Address - Fax:803-247-2650
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EDISTO REGIONAL HEALTH SERVICES INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-01-26
Last Update Date:2017-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC261QR1300X
207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC009OtherBCBS
SC009OtherTRICARE
SCCN8991OtherRRMEDICARE
SCGP44779Medicaid
SC42-3881OtherRHC MEDICAID
SCCK8831OtherRRMEDICARE
SC009OtherBLUECHOICE
SC009OtherTRICARE