Healthcare Provider Details

I. General information

NPI: 1144875774
Provider Name (Legal Business Name): MCLEOD HEALTH CLARENDON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2019
Last Update Date: 08/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 S GEORGETOWN HWY
JOHNSONVILLE SC
29555-8083
US

IV. Provider business mailing address

PO BOX 100567
FLORENCE SC
29502-0567
US

V. Phone/Fax

Practice location:
  • Phone: 843-380-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SAMUEL FULTON ERVIN III
Title or Position: SR VICE PRESIDENT AND CFO
Credential:
Phone: 843-777-2910