Basic Information
| Provider Information | |||||||||
| NPI: | 1528162112 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCLEOD PHYSICIAN ASSOCIATES II | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MCLEOD FAMILY PRACTICE - TIMMONSVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3239 | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295023239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433463900 | ||||||||
| FaxNumber: | 8433467839 | ||||||||
| Practice Location | |||||||||
| Address1: | 755 E SMITH ST | ||||||||
| Address2: | |||||||||
| City: | TIMMONSVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291619430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433463900 | ||||||||
| FaxNumber: | 8433467839 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 03/27/2009 | ||||||||
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| AuthorizedOfficialLastName: | PROVENZANO | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | REGIONAL PRACTICE MANAGER/AVP | ||||||||
| AuthorizedOfficialTelephone: | 8437777030 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MCLEOD HEALTH | ||||||||
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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 | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | RHC170 | 05 | SC | MEDICAID | GP1781 | 05 | SC | MEDICAID | RHC137 | 05 | SC | MEDICAID |