Provider Demographics
NPI:1104975663
Name:MCLEAN SHEPERD, MD, LLC
Entity type:Organization
Organization Name:MCLEAN SHEPERD, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MCLEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEPERD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-216-3530
Mailing Address - Street 1:852 LOWCOUNTRY BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-3067
Mailing Address - Country:US
Mailing Address - Phone:843-216-3530
Mailing Address - Fax:843-654-9122
Practice Address - Street 1:852 LOWCOUNTRY BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3067
Practice Address - Country:US
Practice Address - Phone:843-216-3530
Practice Address - Fax:843-654-9122
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MCLEAN SHEPERD, MD, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-10
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18640174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC186408Medicaid
SCH12449Medicare UPIN
SC186408Medicaid