Healthcare Provider Details

I. General information

NPI: 1396976700
Provider Name (Legal Business Name): EDISTO REGIONAL HEALTH SERVICES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2009
Last Update Date: 07/21/2022
Certification Date: 07/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

651A HARRY C RAYSOR DR
ST MATTHEWS SC
29135-1487
US

IV. Provider business mailing address

PO BOX 1245
ORANGEBURG SC
29116-1245
US

V. Phone/Fax

Practice location:
  • Phone: 803-395-3755
  • Fax: 803-874-3905
Mailing address:
  • Phone: 803-395-4497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateSC

VIII. Authorized Official

Name: CHRISTAL LEANN FULMER
Title or Position: REVENUE INTEGRITY MANAGER
Credential:
Phone: 803-395-4248