Basic Information
Provider Information | |||||||||
NPI: | 1942554886 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BEAUFORT JASPER HAMPTON COMPREHENSIVE HEALTH SERVICES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PORT ROYAL MEDICAL CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GARDNER | ||||||||
AuthorizedOfficialFirstName: | ROLAND | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 8439877400 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
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 |