Basic Information
| Provider Information | |||||||||
| NPI: | 1003130956 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EDISTO REGIONAL HEALTH SERVICES INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | RMC PRIMARY CARE BAMBERG | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1245 | ||||||||
| Address2: | |||||||||
| City: | ORANGEBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291161245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033954497 | ||||||||
| FaxNumber: | 8033952237 | ||||||||
| Practice Location | |||||||||
| Address1: | 498 NORTH STREET | ||||||||
| Address2: | |||||||||
| City: | BAMBERG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290031377 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032455144 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2010 | ||||||||
| LastUpdateDate: | 06/01/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PORTERFIELD | ||||||||
| AuthorizedOfficialFirstName: | LIZA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | C.F.O. | ||||||||
| AuthorizedOfficialTelephone: | 8033954458 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EDISTO REGIONAL HEALTH SERVICES INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 19072 | SC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207V00000X | 22299 | SC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 261QR1300X | 19072 | SC | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | CN8991 | 01 | SC | RRMEDICARE | OTHER | 019 | 01 | SC | BLUECHOICE | OTHER | 017 | 01 | SC | TRICARE | OTHER | GP5405 | 05 | SC | MEDICAID | 019 | 01 | SC | BCBS | OTHER | RHC199 | 01 | SC | MEDICARE RURAL HEALTH | OTHER | CK8831 | 01 | SC | RRMEDICARE | OTHER |