Provider Demographics
NPI:1629041009
Name:MCLEOD PHYSICIAN ASSOCIATES II
Entity Type:Organization
Organization Name:MCLEOD PHYSICIAN ASSOCIATES II
Other - Org Name:MCLEOD FAMILY MEDICINE - HEALTH AND FITNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:
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:843-777-3100
Mailing Address - Fax:843-777-3111
Practice Address - Street 1:2437 WILLWOOD DR
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-3904
Practice Address - Country:US
Practice Address - Phone:843-777-3100
Practice Address - Fax:843-777-3111
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MCLEOD HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-02-08
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2343Medicaid
SC=========043OtherBLUE CHOICE
SCGP2343Medicaid