=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710532486
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MCLEOD HEALTH CHERAW
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2019
-----------------------------------------------------
Last Update Date | 10/04/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3032 E HIGHWAY 76
-----------------------------------------------------
City | MULLINS
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29574-7396
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-464-7111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 100567
-----------------------------------------------------
City | FLORENCE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29502-0567
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SR VP AND CFO
-----------------------------------------------------
Name | SAMUEL FULTON ERVIN III
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 843-777-2910
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------