1275689002 NPI number — MCLEOD PHYSICIAN ASSOCIATES II

Table of content: (NPI 1275689002)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275689002 NPI number — MCLEOD PHYSICIAN ASSOCIATES II

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MCLEOD PHYSICIAN ASSOCIATES II
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MCLEOD FAMILY MEDICINE KINGSTREE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275689002
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/08/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3239
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLORENCE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29502-3239
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-777-7162
Provider Business Mailing Address Fax Number:
843-777-7102

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
512 NELSON BLVD STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KINGSTREE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29556-4027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-355-5459
Provider Business Practice Location Address Fax Number:
843-355-9704
Provider Enumeration Date:
01/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ERVIN
Authorized Official First Name:
SAMUEL
Authorized Official Middle Name:
FULTON
Authorized Official Title or Position:
SR VICE PRESIDENT AND CFO
Authorized Official Telephone Number:
843-777-2910

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X , with the licence number: 11529 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363AM0700X , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: RHC047 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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