Healthcare Provider Details

I. General information

NPI: 1023941879
Provider Name (Legal Business Name): SOUTH OF BROAD HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2026
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 INNOVATION DR
BLUFFTON SC
29910-5159
US

IV. Provider business mailing address

955 RIBAUT RD
BEAUFORT SC
29902-5441
US

V. Phone/Fax

Practice location:
  • Phone: 843-522-5200
  • Fax:
Mailing address:
  • Phone: 843-522-5140
  • Fax: 843-522-5724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number
License Number State

VIII. Authorized Official

Name: EDMOND RUSSELL BAXLEY III
Title or Position: CEO/PRESIDENT
Credential:
Phone: 843-687-9402