Basic Information
| Provider Information | |||||||||
| NPI: | 1144875774 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCLEOD HEALTH CLARENDON | ||||||||
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| OtherOrganizationName: | MCLEOD FAMILY MEDICINE-JOHNSONVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 100567 | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295020567 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 355 S GEORGETOWN HWY | ||||||||
| Address2: | |||||||||
| City: | JOHNSONVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295558083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433802000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2019 | ||||||||
| LastUpdateDate: | 08/14/2019 | ||||||||
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| AuthorizedOfficialLastName: | ERVIN | ||||||||
| AuthorizedOfficialFirstName: | SAMUEL | ||||||||
| AuthorizedOfficialMiddleName: | FULTON | ||||||||
| AuthorizedOfficialTitleorPosition: | SR VICE PRESIDENT AND CFO | ||||||||
| AuthorizedOfficialTelephone: | 8437772910 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | RHC176 | 05 | SC | MEDICAID | 42-8989 | 01 | SC | PTAN | OTHER | GP2568 | 05 | SC | MEDICAID |