Provider Demographics
NPI:1275689002
Name:MCLEOD PHYSICIAN ASSOCIATES II
Entity Type:Organization
Organization Name:MCLEOD PHYSICIAN ASSOCIATES II
Other - Org Name:MCLEOD FAMILY MEDICINE KINGSTREE
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 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:843-777-7162
Mailing Address - Fax:843-777-7102
Practice Address - Street 1:512 NELSON BLVD STE 200
Practice Address - Street 2:
Practice Address - City:KINGSTREE
Practice Address - State:SC
Practice Address - Zip Code:29556-4027
Practice Address - Country:US
Practice Address - Phone:843-355-5459
Practice Address - Fax:843-355-9704
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MCLEOD HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-26
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC207Q00000X, 363AM0700X
SC11529261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCRHC047Medicaid
SC423857Medicare Oscar/Certification
SC423857Medicare Oscar/Certification