Healthcare Provider Details

I. General information

NPI: 1912236225
Provider Name (Legal Business Name): MCLEOD PHYSICIAN ASSOCIATES II
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2009
Last Update Date: 12/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 E MONROE ST
DILLON SC
29536-2557
US

IV. Provider business mailing address

PO BOX 3239
FLORENCE SC
29502-3239
US

V. Phone/Fax

Practice location:
  • Phone: 843-774-6091
  • Fax: 843-841-3814
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3943
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number30392
License Number StateSC

VIII. Authorized Official

Name: DANE FICCO
Title or Position: SR VP
Credential:
Phone: 843-777-7000