Basic Information
| Provider Information | |||||||||
| NPI: | 1972014652 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCLEOD PHYSICIAN ASSOCIATES II | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MCLEOD PRIMARY CARE BENNETTSVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3239 | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295023239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437777162 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1040 MARLBORO WAY STE 1 | ||||||||
| Address2: | |||||||||
| City: | BENNETTSVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295122494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434795890 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2017 | ||||||||
| LastUpdateDate: | 10/20/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ERVIN | ||||||||
| AuthorizedOfficialFirstName: | SAMUEL | ||||||||
| AuthorizedOfficialMiddleName: | FULTON | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VP AND CFO | ||||||||
| AuthorizedOfficialTelephone: | 8437772910 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MCLEOD PHYSICIAN ASSOCIATES II | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.