Healthcare Provider Details

I. General information

NPI: 1700643335
Provider Name (Legal Business Name): MCLEOD REGIONAL MEDICAL CENTER OF THE PEE DEE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/29/2024
Last Update Date: 02/29/2024
Certification Date: 02/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 MCLEOD HEALTH BLVD STE 202
MYRTLE BEACH SC
29579-4477
US

IV. Provider business mailing address

PO BOX 601743
CHARLOTTE NC
28260-1743
US

V. Phone/Fax

Practice location:
  • Phone: 843-839-1201
  • Fax: 843-839-1202
Mailing address:
  • Phone: 843-839-1201
  • Fax: 843-777-7102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SAMUEL FULTON ERVIN III
Title or Position: SR. VP & CFO
Credential:
Phone: 843-777-2910