Provider Demographics
NPI:1306123344
Name:MCLEOD LORIS SEACOAST HOSPITAL
Entity type:Organization
Organization Name:MCLEOD LORIS SEACOAST HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR VP AND CFO
Authorized Official - Prefix:MR
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 1:3655 MITCHELL ST
Mailing Address - Street 2:BOX 690001
Mailing Address - City:LORIS
Mailing Address - State:SC
Mailing Address - Zip Code:29569-2827
Mailing Address - Country:US
Mailing Address - Phone:843-716-7000
Mailing Address - Fax:843-716-7195
Practice Address - Street 1:3655 MITCHELL ST
Practice Address - Street 2:
Practice Address - City:LORIS
Practice Address - State:SC
Practice Address - Zip Code:29569-2827
Practice Address - Country:US
Practice Address - Phone:843-716-7000
Practice Address - Fax:843-716-7195
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MCLEOD HEALTH, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-11-04
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCHTL033282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC4200105Medicaid
SCBHTL33Medicaid
SCAHTL33Medicaid
SCBHTL33Medicaid