Healthcare Provider Details

I. General information

NPI: 1255060679
Provider Name (Legal Business Name): ELIZABETH LELAND VARDELL PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2022
Last Update Date: 06/10/2022
Certification Date: 06/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MCLEOD REGIONAL MEDICAL CENTER - EMERGENCY DEPARTMENT 851 EAST CHEVES STREET
FLORENCE SC
29506
US

IV. Provider business mailing address

555 E CHEVES ST
FLORENCE SC
29506-2617
US

V. Phone/Fax

Practice location:
  • Phone: 843-777-5617
  • Fax: 843-777-5572
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA4412
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: