Healthcare Provider Details

I. General information

NPI: 1861704082
Provider Name (Legal Business Name): JILL BRADDY MCLEOD M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2010
Last Update Date: 12/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 N SUMTER ST STE 200
SUMTER SC
29150-4968
US

IV. Provider business mailing address

PO BOX 743904
ATLANTA GA
30384-3904
US

V. Phone/Fax

Practice location:
  • Phone: 803-775-8351
  • Fax: 803-774-1512
Mailing address:
  • Phone: 803-296-7320
  • Fax: 803-296-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberLL32635
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number32635
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: