Provider Demographics
NPI:1508218793
Name:MCLEOD HEALTH CLARENDON
Entity Type:Organization
Organization Name:MCLEOD HEALTH CLARENDON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR VICE PRESIDENT AND CFO
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:F
Authorized Official - Last Name:ERVIN
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:843-777-2910
Mailing Address - Street 1:10 E HOSPITAL ST
Mailing Address - Street 2:
Mailing Address - City:MANNING
Mailing Address - State:SC
Mailing Address - Zip Code:29102-3153
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 E HOSPITAL ST
Practice Address - Street 2:
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102-3153
Practice Address - Country:US
Practice Address - Phone:843-435-8463
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MCLEOD HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-07-12
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP7479Medicaid
SCG064OtherMEDICARE