Provider Demographics
NPI:1003461773
Name:MCLEOD HEALTH CLARENDON
Entity Type:Organization
Organization Name:MCLEOD HEALTH CLARENDON
Other - Org Name:MCLEOD FAMILY MEDICINE-TIMMONSVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VICE PRESIDENT AND CFO
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:FULTON
Authorized Official - Last Name:ERVIN
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:843-777-2910
Mailing Address - Street 1:PO BOX 100567
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29502-0567
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:755 E SMITH ST
Practice Address - Street 2:
Practice Address - City:TIMMONSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29161-9430
Practice Address - Country:US
Practice Address - Phone:843-346-3900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-08
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCRHC137Medicaid
SCGP1781Medicaid
SC42-8962OtherPTAN
SCRHC170Medicaid