MEDICARE: MCLEOD PHYSICIAN ASSOCIATES II

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR1300X	Rural Health Clinic/Center

General Provider Information

NPI Number	:	1114204153
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MCLEOD PHYSICIAN ASSOCIATES II

Provider Business Mailing Address
First Line	:	PO BOX 3239
Second Line	:
City	:	FLORENCE
State	:	SC
Zip	:	29502-3239
Country	:	US
Telephone Number	:	843-777-7010
Fax Number	:	843-777-7006

Provider Business Practice Location Address
First Line	:	5260 HIGHWAY 9
Second Line	:
City	:	GREEN SEA
State	:	SC
Zip	:	29545-4930
Country	:	US
Telephone Number	:	843-392-9222
Fax Number	:	843-392-1445

Authorized Official
Title or Position	:	SENIOR VICE PRESIDENT
Name	:	MR. DANE P FICCO
Credential	:
Telephone Number	:	843-777-7012

Provider Enumeration Date	:	11/04/2011
Last Update Date	:	12/06/2011

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