Provider Demographics
NPI:1215991682
Name:MCLEOD REGIONAL MEDICAL CENTER OF THE PEE DEE, INC
Entity type:Organization
Organization Name:MCLEOD REGIONAL MEDICAL CENTER OF THE PEE DEE, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR VP AND CFO
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:FULTON
Authorized Official - Last Name:ERVIN
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:843-777-2910
Mailing Address - Street 1:2210 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-1109
Mailing Address - Country:US
Mailing Address - Phone:843-777-3050
Mailing Address - Fax:843-777-5368
Practice Address - Street 1:2210 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-1109
Practice Address - Country:US
Practice Address - Phone:843-669-3050
Practice Address - Fax:843-669-5368
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MCLEOD HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-04-13
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCHHA-085251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC470573Medicaid
SCPP0001Medicaid
SC470573Medicaid
SCPP0001Medicaid