Basic Information
Provider Information | |||||||||
NPI: | 1346344934 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MCLEOD PHYSICIAN ASSOCIATES II | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MCLEOD PEDIATRICS - DILLON | ||||||||
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: | 8437746091 | ||||||||
FaxNumber: | 8438413814 | ||||||||
Practice Location | |||||||||
Address1: | 705 N 8TH AVE | ||||||||
Address2: | STE 3A | ||||||||
City: | DILLON | ||||||||
State: | SC | ||||||||
PostalCode: | 295362549 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8437746091 | ||||||||
FaxNumber: | 8438413814 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/12/2006 | ||||||||
LastUpdateDate: | 06/03/2022 | ||||||||
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: | 06/03/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 261QR1300X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 208000000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | RHC162 | 05 | SC |   | MEDICAID | GP1967 | 05 | SC |   | MEDICAID |