MEDICARE: EDISTO REGIONAL HEALTH SERVICES INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician		SC

General Provider Information

NPI Number	:	1346644119
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDISTO REGIONAL HEALTH SERVICES INC.

Provider Business Mailing Address
First Line	:	PO BOX 1245
Second Line	:
City	:	ORANGEBURG
State	:	SC
Zip	:	29116-1245
Country	:	US
Telephone Number	:	803-395-4497
Fax Number	:	803-395-2237

Provider Business Practice Location Address
First Line	:	1728 VILLAGE PARK DR
Second Line	:
City	:	ORANGEBURG
State	:	SC
Zip	:	29118-2426
Country	:	US
Telephone Number	:	803-536-1106
Fax Number	:	803-535-6033

Authorized Official
Title or Position	:	C.F.O.
Name	:	CHERYL S. MASON
Credential	:
Telephone Number	:	803-395-2224

Provider Enumeration Date	:	10/22/2014
Last Update Date	:	10/22/2014

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