Basic Information
Provider Information | |||||||||
NPI: | 1275912974 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MCLEOD HEALTH CHERAW | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MCLEOD HEALTH CHERAW PHYSICIANS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 100567 | ||||||||
Address2: |   | ||||||||
City: | FLORENCE | ||||||||
State: | SC | ||||||||
PostalCode: | 295020567 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8437774400 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 711 CHESTERFIELD HWY | ||||||||
Address2: |   | ||||||||
City: | CHERAW | ||||||||
State: | SC | ||||||||
PostalCode: | 295207002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8435377881 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/27/2015 | ||||||||
LastUpdateDate: | 02/25/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ERVIN | ||||||||
AuthorizedOfficialFirstName: | SAMUEL | ||||||||
AuthorizedOfficialMiddleName: | F | ||||||||
AuthorizedOfficialTitleorPosition: | SR. VICE PRESIDENT AND CFO | ||||||||
AuthorizedOfficialTelephone: | 8437772910 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MCLEOD HEALTH | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: | III | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 367500000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | F237 | 01 | SC | MEDICARE | OTHER | GP7142 | 05 | SC |   | MEDICAID |