Provider Demographics
NPI:1548529696
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:CHERYL
Authorized Official - Middle Name:S
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-395-2224
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:803-536-0998
Practice Address - Street 1:1750 VILLAGE PARK DR
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-2457
Practice Address - Country:US
Practice Address - Phone:803-534-4254
Practice Address - Fax:803-531-8810
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EDISTO REGIONAL HEALTH SERVICES INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-10
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC42-8966Medicare PIN
SC5677Medicare PIN