1790134781 NPI number — MCLEOD PHYSICIAN ASSOCIATES II

Table of content: (NPI 1790134781)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790134781 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:
1790134781
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/09/2016
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:
843-777-7120
Provider Business Mailing Address Fax Number:
843-777-7102

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
690 SUNSET BLVD N
Provider Second Line Business Practice Location Address:
SUITE 109
Provider Business Practice Location Address City Name:
SUNSET BEACH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28468-5332
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-399-9774
Provider Business Practice Location Address Fax Number:
843-399-8657
Provider Enumeration Date:
06/09/2016

Additional Information

Authorized Official

Authorized Official Last Name:
FICCO
Authorized Official First Name:
DANE
Authorized Official Middle Name:
Authorized Official Title or Position:
SENIOR VICE PRESIDENT
Authorized Official Telephone Number:
843-777-7010

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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