Provider Demographics
NPI:1619994233
Name:MCLEOD PHYSICIAN ASSOCIATES II
Entity Type:Organization
Organization Name:MCLEOD PHYSICIAN ASSOCIATES II
Other - Org Name:PEE DEE SURGICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP
Authorized Official - Prefix:MR
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:843-665-7941
Mailing Address - Fax:843-665-1257
Practice Address - Street 1:800 E CHEVES ST
Practice Address - Street 2:STE 260
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2652
Practice Address - Country:US
Practice Address - Phone:843-665-7941
Practice Address - Fax:843-665-1257
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MCLEOD HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-17
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1701Medicaid
SCGP1701Medicaid
SC=========001OtherBLUE CHOICE