Basic Information
Provider Information | |||||||||
NPI: | 1457005431 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BEAUFORT JASPER HAMPTON COMPREHENSIVE HEALTH SERVICES, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PORT ROYAL OB/GYN | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 357 | ||||||||
Address2: |   | ||||||||
City: | RIDGELAND | ||||||||
State: | SC | ||||||||
PostalCode: | 299362605 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8439877400 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1264 RIBAUT RD STE 200 | ||||||||
Address2: |   | ||||||||
City: | BEAUFORT | ||||||||
State: | SC | ||||||||
PostalCode: | 299026127 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8439877400 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/08/2022 | ||||||||
LastUpdateDate: | 02/15/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GARDNER | ||||||||
AuthorizedOfficialFirstName: | ROLAND | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 8439877400 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/15/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X |   |   | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   | 261QF0050X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Family Planning, Non-Surgical | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.