Basic Information
Provider Information | |||||||||
NPI: | 1598080079 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EDISTO REGIONAL HEALTH SERVICES INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WILLIAM D. GLENN IV MD | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1245 | ||||||||
Address2: |   | ||||||||
City: | ORANGEBURG | ||||||||
State: | SC | ||||||||
PostalCode: | 291161245 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8033954497 | ||||||||
FaxNumber: | 8035360998 | ||||||||
Practice Location | |||||||||
Address1: | 5073 CAROLINA HWY | ||||||||
Address2: |   | ||||||||
City: | DENMARK | ||||||||
State: | SC | ||||||||
PostalCode: | 290421679 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8032455144 | ||||||||
FaxNumber: | 8032456277 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/29/2010 | ||||||||
LastUpdateDate: | 03/31/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GOODLETT | ||||||||
AuthorizedOfficialFirstName: | LISA | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | C.O.O. | ||||||||
AuthorizedOfficialTelephone: | 8033952462 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 19072 | SC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.