Provider Demographics
NPI:1003889593
Name:MCLEOD PHYSICIAN ASSOCIATES II
Entity Type:Organization
Organization Name:MCLEOD PHYSICIAN ASSOCIATES II
Other - Org Name:MEDICAL PLAZA FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:D
Authorized Official - Last Name:BEASLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-777-7010
Mailing Address - Street 1:PO BOX 3239
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29502-3239
Mailing Address - Country:US
Mailing Address - Phone:843-679-7272
Mailing Address - Fax:843-679-7215
Practice Address - Street 1:800 E CHEVES ST
Practice Address - Street 2:STE 310
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2652
Practice Address - Country:US
Practice Address - Phone:843-679-7272
Practice Address - Fax:843-679-7215
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MCLEOD HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-02-07
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1646Medicaid
SC=========007OtherBLUE CHOICE
SC=========007OtherBLUE CROSS BLUE SHIELD