Provider Demographics
NPI:1083067714
Name:MCLEOD PHYSICIAN ASSOCIATES II
Entity Type:Organization
Organization Name:MCLEOD PHYSICIAN ASSOCIATES II
Other - Org Name:MCLEOD PRIMARY CARE CLARENDON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANE
Authorized Official - Middle Name:P
Authorized Official - Last Name:FICCO
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:843-777-7487
Mailing Address - Fax:843-777-7102
Practice Address - Street 1:22 BOZARD ST
Practice Address - Street 2:
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102-2935
Practice Address - Country:US
Practice Address - Phone:803-435-8828
Practice Address - Fax:803-435-2239
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MCLEOD HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-07-18
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty