Healthcare Provider Details

I. General information

NPI: 1639446750
Provider Name (Legal Business Name): MCLEOD PHYSICIAN ASSOCIATES II
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2011
Last Update Date: 11/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7209 HIGHWAY 90 SUITE C
LONGS SC
29568-6236
US

IV. Provider business mailing address

PO BOX 3239
FLORENCE SC
29502-3239
US

V. Phone/Fax

Practice location:
  • Phone: 843-390-1800
  • Fax:
Mailing address:
  • Phone: 843-777-7122
  • Fax: 843-777-7102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateSC

VIII. Authorized Official

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