Healthcare Provider Details

I. General information

NPI: 1942430871
Provider Name (Legal Business Name): EDISTO REGIONAL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2009
Last Update Date: 01/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 HARRY C RAYSOR DR
ST MATTHEWS SC
29135-8403
US

IV. Provider business mailing address

PO BOX 1245
ORANGEBURG SC
29116-1245
US

V. Phone/Fax

Practice location:
  • Phone: 803-874-3902
  • Fax: 803-874-3905
Mailing address:
  • Phone: 803-395-4497
  • Fax: 803-536-0998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LISA M GOODLETT
Title or Position: C.O.O.
Credential:
Phone: 803-395-2200