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	261QU0200X	Urgent Care Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1467550087
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	:

Provider Business Practice Location Address
First Line	:	111 JOHN LAWSON AVE
Second Line	:
City	:	SANTEE
State	:	SC
Zip	:	29142-8654
Country	:	US
Telephone Number	:	803-395-2070
Fax Number	:	803-395-2097

Authorized Official
Title or Position	:	MANAGER
Name	:	CHRISTAL LEANN FULMER
Credential	:
Telephone Number	:	803-395-4248

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	06/20/2022

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Directions to “EDISTO REGIONAL HEALTH SERVICES INC ” Practice Location

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