Healthcare Provider Details

I. General information

NPI: 1073476198
Provider Name (Legal Business Name): EDISTO MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2025
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 JUNGLE RD
EDISTO ISLAND SC
29438-3005
US

IV. Provider business mailing address

134 JUNGLE RD
EDISTO ISLAND SC
29438-3005
US

V. Phone/Fax

Practice location:
  • Phone: 843-897-7757
  • Fax: 843-897-7877
Mailing address:
  • Phone: 843-897-7757
  • Fax: 843-897-7877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY DAWN RAKES-STEPHENS
Title or Position: MD
Credential:
Phone: 843-217-1695