Basic Information
| Provider Information | |||||||||
| NPI: | 1336180165 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BEAUFORT COUNTY MEMORIAL HOSPITAL | ||||||||
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| OtherOrganizationName: | BEAUFORT MEMORIAL LOWCOUNTRY MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 955 RIBAUT RD | ||||||||
| Address2: | BMAC CREDENTIALING | ||||||||
| City: | BEAUFORT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299025441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435227843 | ||||||||
| FaxNumber: | 8435225678 | ||||||||
| Practice Location | |||||||||
| Address1: | BEAUFORT MEMORIAL LOWCOUNTRY MEDICAL GROUP | ||||||||
| Address2: | 300 MIDTOWN | ||||||||
| City: | BEAUFORT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299065200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437700404 | ||||||||
| FaxNumber: | 8442962308 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 10/21/2020 | ||||||||
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| AuthorizedOfficialLastName: | BAXLEY | ||||||||
| AuthorizedOfficialFirstName: | EDMUND | ||||||||
| AuthorizedOfficialMiddleName: | RUSSELL | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8435225140 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BEAUFORT COUNTY MEMORIAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 101376 | 05 | SC | MEDICAID | 3257 | 01 | MEDICARE ID-TYPE UNSPECIFIED MEDICARE PART B | OTHER | 270920 | 05 | SC | MEDICAID | GP6561 | 05 | SC | MEDICAID |