Provider Demographics
NPI:1952350142
Name:EDISTO REGIONAL HEALTH SERVICES INC.
Entity Type:Organization
Organization Name:EDISTO REGIONAL HEALTH SERVICES INC.
Other - Org Name:FAMILY PRACTICE ASSOCIATES OF HOLLY HILL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:C.O.O
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GOODLETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-395-2462
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:HOLLY HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29059-0188
Mailing Address - Country:US
Mailing Address - Phone:803-395-4480
Mailing Address - Fax:803-395-4499
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
Practice Address - Country:US
Practice Address - Phone:803-496-3312
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2353Medicaid
SC5677Medicare PIN