Basic Information
| Provider Information | |||||||||
| NPI: | 1114204153 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCLEOD PHYSICIAN ASSOCIATES II | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FAMILY HEALTH CENTER - MT. OLIVE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3239 | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295023239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437777010 | ||||||||
| FaxNumber: | 8437777006 | ||||||||
| Practice Location | |||||||||
| Address1: | 5260 HIGHWAY 9 | ||||||||
| Address2: | |||||||||
| City: | GREEN SEA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295454930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433929222 | ||||||||
| FaxNumber: | 8433921445 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2011 | ||||||||
| LastUpdateDate: | 12/06/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FICCO | ||||||||
| AuthorizedOfficialFirstName: | DANE | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8437777012 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MCLEOD HEALTH, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.