=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356314819
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MCLEOD PHYSICIAN ASSOCIATES II
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2006
-----------------------------------------------------
Last Update Date | 01/07/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 WILLIAM H. JOHNSON STREET STE 350
-----------------------------------------------------
City | FLORENCE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29506-2775
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-777-6065
-----------------------------------------------------
Fax | 843-777-6069
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3239
-----------------------------------------------------
City | FLORENCE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29502-3239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-777-6065
-----------------------------------------------------
Fax | 843-777-6069
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | BRAD COLE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 843-777-7010
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------