Basic Information
| Provider Information | |||||||||
| NPI: | 1013060953 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EDISTO REGIONAL HEALTH SERVICES, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | RMC PRIMARY CARE HOLLY HILL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 187 BUNCH FORD ROAD | ||||||||
| Address2: | |||||||||
| City: | HOLLY HILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290598224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034963312 | ||||||||
| FaxNumber: | 8034967713 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 10/23/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MASON | ||||||||
| AuthorizedOfficialFirstName: | CHERYL | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | C.F.O. | ||||||||
| AuthorizedOfficialTelephone: | 8033952224 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EDISTO REGIONAL HEALTH SERVICES, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | CK8831 | 01 | SC | RRMEDICARE | OTHER | CN8991 | 01 | SC | RRMEDICARE | OTHER | RHC012 | 05 | SC | MEDICAID | GP2353 | 05 | SC | MEDICAID | 004 | 01 | SC | BCBS | OTHER | 003 | 01 | SC | TRICARE | OTHER | 004 | 01 | SC | BLUECHOICE | OTHER |