Basic Information
| Provider Information | |||||||||
| NPI: | 1942554886 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BEAUFORT JASPER HAMPTON COMPREHENSIVE HEALTH SERVICES, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PORT ROYAL MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 721 N OKATIE HWY # 170 | ||||||||
| Address2: | |||||||||
| City: | RIDGELAND | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299368276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8439877400 | ||||||||
| FaxNumber: | 8439877498 | ||||||||
| Practice Location | |||||||||
| Address1: | 1320 RIBAUT RD | ||||||||
| Address2: | |||||||||
| City: | PORT ROYAL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299351118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8439860900 | ||||||||
| FaxNumber: | 8439860566 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2012 | ||||||||
| LastUpdateDate: | 08/09/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GARDNER | ||||||||
| AuthorizedOfficialFirstName: | ROLAND | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8439877400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | GP2554 | SC | N | Ambulatory Health Care Facilities | Clinic/Center | Community Health | 261QD0000X | 295441 | SC | N | Ambulatory Health Care Facilities | Clinic/Center | Dental | 261QM1300X | CBP005 | SC | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 261QM2500X | FQC102 | SC | N | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty | 261QR0206X | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mammography | 261QF0400X | FQC102 | SC | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | FQC102 | 05 | SC | MEDICAID |