Basic Information
| Provider Information | |||||||||
| NPI: | 1841595667 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EDISTO REGIONAL HEALTH SERVICES INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | RMC PRIMARY CARE NORTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1245 | ||||||||
| Address2: | |||||||||
| City: | ORANGEBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291161245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033954762 | ||||||||
| FaxNumber: | 8035360998 | ||||||||
| Practice Location | |||||||||
| Address1: | 4631 SAVANNAH HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | NORTH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291128180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032472428 | ||||||||
| FaxNumber: | 8032472650 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2011 | ||||||||
| LastUpdateDate: | 09/28/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PORTERFIELD | ||||||||
| AuthorizedOfficialFirstName: | LIZA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | C F O | ||||||||
| AuthorizedOfficialTelephone: | 8033954458 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EDISTO REGIONAL HEALTH SERVICES INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | SC | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 009 | 01 | SC | BCBS | OTHER | 009 | 01 | SC | TRICARE | OTHER | CN8991 | 01 | SC | RRMEDICARE | OTHER | GP44779 | 05 | SC | MEDICAID | 42-3881 | 01 | SC | RHC MEDICAID | OTHER | CK8831 | 01 | SC | RRMEDICARE | OTHER | 009 | 01 | SC | BLUECHOICE | OTHER |