1417110032 NPI number — EDGEFIELD COUNTY HOSPITAL

Table of content: (NPI 1417110032)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417110032 NPI number — EDGEFIELD COUNTY HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDGEFIELD COUNTY HOSPITAL
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417110032
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/22/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
155 RIDGE MEDICAL PLAZA
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
EDGEFIELD
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29824-4535
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-637-3630
Provider Business Mailing Address Fax Number:
803-637-5348

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
155 RIDGE MEDICAL PLAZA
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
EGEFIELD
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29824-4535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-637-3630
Provider Business Practice Location Address Fax Number:
803-637-5348
Provider Enumeration Date:
07/03/2008

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
W
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
803-637-3630

Provider Taxonomy Codes

  • Taxonomy code: 282NC0060X , with the licence number:  HTL479 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X , with the licence number: HTL479 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: RHC548 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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