Basic Information
Provider Information | |||||||||
NPI: | 1245752294 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MCLEOD PHYSICIAN ASSOCIATES II | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MCLEOD MED SHARE CAROLINA FOREST | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3239 | ||||||||
Address2: |   | ||||||||
City: | FLORENCE | ||||||||
State: | SC | ||||||||
PostalCode: | 295023239 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8437777122 | ||||||||
FaxNumber: | 8437777102 | ||||||||
Practice Location | |||||||||
Address1: | 907 STARTEK DR | ||||||||
Address2: |   | ||||||||
City: | MYRTLE BEACH | ||||||||
State: | SC | ||||||||
PostalCode: | 295794471 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8437777010 | ||||||||
FaxNumber: | 8437777006 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2017 | ||||||||
LastUpdateDate: | 06/07/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BEASLEY | ||||||||
AuthorizedOfficialFirstName: | KENNETH | ||||||||
AuthorizedOfficialMiddleName: | D. | ||||||||
AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8437777010 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MCLEOD HEALTH | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/07/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X |   | SC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 363A00000X |   | SC | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363L00000X |   | SC | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 207RC0000X |   | SC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 208600000X |   | SC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   |
No ID Information.