Basic Information
| Provider Information | |||||||||
| NPI: | 1497134852 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MCLEOD PHYSICIAN ASSOCIATES II | ||||||||
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| OtherOrganizationName: | MCLEOD PRIMARY CARE BENNETTSVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3239 | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295023239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437777162 | ||||||||
| FaxNumber: | 8437777102 | ||||||||
| Practice Location | |||||||||
| Address1: | 1040 MARLBORO WAY | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | BENNETTSVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295122494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434795890 | ||||||||
| FaxNumber: | 8434793524 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2015 | ||||||||
| LastUpdateDate: | 05/19/2015 | ||||||||
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| AuthorizedOfficialLastName: | FICCO | ||||||||
| AuthorizedOfficialFirstName: | DANE | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8437777010 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MCLEOD HEALTH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | SC | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207Q00000X | SC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.