Healthcare Provider Details

I. General information

NPI: 1285641332
Provider Name (Legal Business Name): EDISTO REGIONAL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 10/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 PELHAM CT
ORANGEBURG SC
29118-1400
US

IV. Provider business mailing address

PO BOX 1245
ORANGEBURG SC
29116-1245
US

V. Phone/Fax

Practice location:
  • Phone: 803-655-6132
  • Fax: 803-655-6173
Mailing address:
  • Phone: 803-395-4499
  • Fax: 803-395-4480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberAPN652
License Number StateSC

VIII. Authorized Official

Name: THOMAS DANDRIDGE I
Title or Position: PRESIDENT
Credential:
Phone: 803-395-2200