Provider Demographics
NPI:1366766222
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.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 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 1:498 NORTH ST
Practice Address - Street 2:
Practice Address - City:BAMBERG
Practice Address - State:SC
Practice Address - Zip Code:29003-1377
Practice Address - Country:US
Practice Address - Phone:803-245-5144
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-22
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19072207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC5677Medicare PIN