1548436777 NPI number — MCLEOD PHYSICIAN ASSOCIATES II

Table of content: (NPI 1548436777)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548436777 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:
1548436777
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/03/2022
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:
843-841-3517
Provider Business Mailing Address Fax Number:
843-841-3519

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
705 N 8TH AVE
Provider Second Line Business Practice Location Address:
SUITE 1B
Provider Business Practice Location Address City Name:
DILLON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29536-2549
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-487-1588
Provider Business Practice Location Address Fax Number:
843-487-1597
Provider Enumeration Date:
05/07/2008

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: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207XX0005X , with the licence number: DO 457 , 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: GP1968 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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