Provider Demographics
NPI:1497103618
Name:MCLEOD HEALTH CLARENDON
Entity Type:Organization
Organization Name:MCLEOD HEALTH CLARENDON
Other - Org Name:MCLEOD WOMEN'S CARE CLARENDON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VICE PRESIDENT AND CFO
Authorized Official - Prefix:MR
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 1:50 E HOSPITAL ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:MANNING
Mailing Address - State:SC
Mailing Address - Zip Code:29102-3149
Mailing Address - Country:US
Mailing Address - Phone:803-435-5250
Mailing Address - Fax:
Practice Address - Street 1:50 E HOSPITAL ST
Practice Address - Street 2:SUITE 4
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102-3149
Practice Address - Country:US
Practice Address - Phone:803-435-5250
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MCLEOD HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-27
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCRHC244Medicaid
SC42-3459OtherMEDICARE