Basic Information
| Provider Information | |||||||||
| NPI: | 1306123344 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCLEOD LORIS SEACOAST HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | LORIS COMMUNITY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3655 MITCHELL ST | ||||||||
| Address2: | BOX 690001 | ||||||||
| City: | LORIS | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295692827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437167000 | ||||||||
| FaxNumber: | 8437167195 | ||||||||
| Practice Location | |||||||||
| Address1: | 3655 MITCHELL ST | ||||||||
| Address2: | |||||||||
| City: | LORIS | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295692827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437167000 | ||||||||
| FaxNumber: | 8437167195 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2011 | ||||||||
| LastUpdateDate: | 02/25/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ERVIN | ||||||||
| AuthorizedOfficialFirstName: | SAMUEL | ||||||||
| AuthorizedOfficialMiddleName: | FULTON | ||||||||
| AuthorizedOfficialTitleorPosition: | SR VP AND CFO | ||||||||
| AuthorizedOfficialTelephone: | 8437772910 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MCLEOD HEALTH, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | HTL033 | SC | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 4200105 | 05 | NC | MEDICAID | BHTL33 | 05 | SC | MEDICAID | AHTL33 | 05 | SC | MEDICAID |