Healthcare Provider Details

I. General information

NPI: 1104899145
Provider Name (Legal Business Name): MCLEOD PHYSICIAN ASSOCIATES II
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 06/03/2022
Certification Date: 06/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 WILLIAM H JOHNSON ST STE 370
FLORENCE SC
29506-2769
US

IV. Provider business mailing address

PO BOX 3239
FLORENCE SC
29502-3239
US

V. Phone/Fax

Practice location:
  • Phone: 437-777-0208
  • Fax: 843-664-9545
Mailing address:
  • Phone: 843-664-0221
  • Fax: 843-664-9545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: KENNETH D. BEASLEY
Title or Position: SENIOR VICE PRESIDENT
Credential:
Phone: 843-777-7010