Basic Information
| Provider Information | |||||||||
| NPI: | 1003410903 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCLEOD HEALTH CHERAW | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MCLEOD FAMILY MEDICINE - DARLINGTON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 701 CASHUA FERRY RD | ||||||||
| Address2: | |||||||||
| City: | DARLINGTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295328488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433988500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 701 CASHUA FERRY RD | ||||||||
| Address2: | |||||||||
| City: | DARLINGTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295328488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433988500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2020 | ||||||||
| LastUpdateDate: | 02/17/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ERVIN | ||||||||
| AuthorizedOfficialFirstName: | SAMUEL | ||||||||
| AuthorizedOfficialMiddleName: | FULTON | ||||||||
| AuthorizedOfficialTitleorPosition: | SR. VP AND CFO | ||||||||
| AuthorizedOfficialTelephone: | 8437772910 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MCLEOD HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 42-3416 | 01 | SC | MEDICARE | OTHER |