1194090720 NPI number — MCLEOD PHYSICIAN ASSOCIATES II

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194090720 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:
Provider Other Organization Name Type Code:
6
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:
1194090720
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/17/2023
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:
843-777-7042
Provider Business Mailing Address Fax Number:
843-777-7102

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3793 MCDOWELL LANE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
LITTLE RIVER
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29566-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-390-0100
Provider Business Practice Location Address Fax Number:
843-390-0038
Provider Enumeration Date:
03/15/2012

Additional Information

Authorized Official

Authorized Official Last Name:
BEASLEY
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
SENIOR VICE PRESIDENT
Authorized Official Telephone Number:
843-777-7010

Provider Taxonomy Codes

  • Taxonomy code: 207QS0010X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GP5874 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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