Basic Information
| Provider Information | |||||||||
| NPI: | 1598713117 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BEAUFORT COUNTY MEMORIAL HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 955 RIBAUT RD | ||||||||
| Address2: | BMAC CREDENTIALING COORDINATOR | ||||||||
| City: | BEAUFORT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299025441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435225790 | ||||||||
| FaxNumber: | 8435225945 | ||||||||
| Practice Location | |||||||||
| Address1: | BEAUFORT MEMORIAL PRIMARY CARE | ||||||||
| Address2: | 989 RIBAUT RD, STE 260 | ||||||||
| City: | BEAUFORT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299025499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435227600 | ||||||||
| FaxNumber: | 8442959674 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 10/21/2020 | ||||||||
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| AuthorizedOfficialLastName: | BAXLEY | ||||||||
| AuthorizedOfficialFirstName: | EDMOND | ||||||||
| AuthorizedOfficialMiddleName: | RUSSELL | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8435225140 | ||||||||
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| 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 | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.