Basic Information
| Provider Information | |||||||||
| NPI: | 1801326814 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MCLEOD PHYSICIAN ASSOCIATES II | ||||||||
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| OtherOrganizationName: | MCLEOD DERMATOLOGY ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3239 | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295023239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437777120 | ||||||||
| FaxNumber: | 8437777102 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 E CHEVES ST STE 302 | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295062615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437779360 | ||||||||
| FaxNumber: | 8437779361 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2017 | ||||||||
| LastUpdateDate: | 01/18/2018 | ||||||||
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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 | 207ND0101X | SC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery | 207ND0900X | SC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207N00000X | SC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.