Provider Demographics
NPI:1710532486
Name:MCLEOD HEALTH CHERAW
Entity Type:Organization
Organization Name:MCLEOD HEALTH CHERAW
Other - Org Name:MCLEOD FAMILY MEDICINE-MARION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP 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 100567
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29502-0567
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3032 E HIGHWAY 76
Practice Address - Street 2:
Practice Address - City:MULLINS
Practice Address - State:SC
Practice Address - Zip Code:29574-7396
Practice Address - Country:US
Practice Address - Phone:843-464-7111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-08
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC42-8927OtherPTAN
SCRHC169Medicaid
SCRHC194Medicaid