NPIMap

Organization Active NPI

McLeod Health Clarendon

Doing business as McLeod Family Medicine-Timmonsville

  • Rural Health Clinic/Center
  • Timmonsville, SC
National Provider Identifier
1003461773
Registry record updated Aug 14, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
MCLEOD HEALTH CLARENDON
Doing business as
McLeod Family Medicine-Timmonsville
Practice address
755 E Smith St
Timmonsville, SC 29161-9430
Phone
(843) 346-3900
NPI assigned
Aug 8, 2019
Last updated
Aug 14, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 14, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Samuel Fulton Ervin III
Title
Sr Vice President and Cfo
Phone
(843) 777-2910

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

755 E Smith St
Timmonsville, SC 29161-9430

Mailing address

PO Box 100567
Florence, SC 29502-0567

Other names 1

  • McLeod Family Medicine-Timmonsville Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in SC2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20160915000930 SC Part B Supplier - Clinic/Group Practice 0840582656 Receives reassigned benefits from 214 practitioners
6 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Timmonsville, SC; Manning, SC; Kingstree, SC; Johnsonville, SC
O20190909003930 SC Part A Provider - Rural Health Clinic 0840582656 Practice locations: Timmonsville, SC

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1003461773. Details of each certification follow.

Rural health clinic certification: CCN 423468

Legal name
MCLEOD HEALTH CLARENDON
Doing business as
MCLEOD FAMILY MEDICINE-TIMMONSVILLE
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Aug 15, 2019
Last certification
Dec 10, 2024
Ownership / control type
1B
Organization structure
CorporationNon-profit
Incorporated
May 27, 2016 in SC
Enrollment address
755 E Smith St
Timmonsville, SC 29161-9430
Related CCNs
42D0929081

Other NPIs with the same Medicare PAC ID 8

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 6

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
McLeod Health Clarendon9 organizations share this tax ID, including this one

Other organizations with this tax ID 8

Organizations that report the same tax identification number in the National Provider Directory.

Locations

1185 Wilson Hall Rd
Sumter, SC 29150
Phone (803) 469-3213

Ownership & related parties

All disclosed owners & managing parties 27

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Willie E Boyd Individual Corporate OfficerBoard of Trustees Jul 12, 2016
Vinod K Jona Individual Corporate OfficerBoard of Trustees Jan 1, 2021
Steven R Ross Individual Corporate OfficerBoard of Directors Jul 12, 2016
Rachel T Gainey Individual W-2 Managing EmployeeVP/Administrator Jul 12, 2016
Frances S Jones Individual Corporate OfficerBoard of Directors Jul 12, 2016
Ashley Brady Individual Corporate OfficerBoard of Directors Jul 12, 2019
William N Boulware Individual Corporate OfficerBoard of Directors Jul 12, 2016
Allie E Brooks Individual Corporate OfficerBoard of Directors Jul 12, 2016
Benjamin T Zeigler Individual Corporate OfficerBoard of Directors Jul 12, 2016
Ronald M Fowler Individual Corporate OfficerBoard of Directors Jul 12, 2016
Dudley B. Harrington Individual Corporate OfficerVP of Business Operations Jul 12, 2016
Jeannette Glenn Individual Corporate OfficerBoard of Directors Jul 12, 2016
McLeod Health Organization, Florence, SC Corporation, Non-profit 5% Or Greater Direct Ownership Interest Jul 12, 2016 100%
Samuel F Ervin Individual Corporate OfficerSenior VP and Cfo Jul 12, 2016
Raymond Clark Individual Corporate OfficerBoard of Directors Jul 12, 2016
Hugh S Blair Individual Corporate OfficerBoard of Directors Jul 12, 2016
Mary Anderson Individual Corporate OfficerBoard of Directors Jul 16, 2016
Tracy Ray Individual Corporate OfficerBoard of Directors Jul 12, 2016
Donna Isgett Individual Corporate OfficerBoard of Trustees Mar 1, 2021
Tarek M Bishara Individual Corporate OfficerBoard of Directors Jul 12, 2016
Beverly Hazelwood Individual Corporate OfficerBoard of Directors Jul 12, 2016
Frank V Boulineau Individual Corporate OfficerBoard of Directors Jul 12, 2016
Michael R Rose Individual Corporate OfficerBoard of Directors Jul 12, 2016
Patrick Kerry Denton Individual Corporate OfficerBoard of Directors Jul 12, 2016
Frank J Brand Individual Corporate OfficerBoard of Directors Jul 12, 2016
James C Smith Individual Corporate OfficerBoard of Directors Jul 12, 2016
John R Braddy Individual Corporate OfficerBoard of Directors Jul 12, 2016

Owners & managing parties with NPI records 7

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 17

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 17

Change-of-ownership history 1

DateEventCounterparty
Aug 15, 2019 Change of OwnershipThis provider was the buyer McLeod Family Practice TimmonsvilleCCN 428962, SC, NPI 1528162112

Change of ownership 1

Medicare changes of ownership in which this facility was the buyer or the seller.

Practitioners & affiliated clinicians

Practitioners 224

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 224

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1565222400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1565740800000",
    "number": "1003461773",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 100567",
            "city": "FLORENCE",
            "state": "SC",
            "postal_code": "295020567"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "755 E SMITH ST",
            "city": "TIMMONSVILLE",
            "state": "SC",
            "postal_code": "291619430",
            "telephone_number": "843-346-3900"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MCLEOD HEALTH CLARENDON",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-08-08",
        "last_updated": "2019-08-14",
        "status": "A",
        "authorized_official_last_name": "ERVIN",
        "authorized_official_first_name": "SAMUEL",
        "authorized_official_middle_name": "FULTON",
        "authorized_official_title_or_position": "SR VICE PRESIDENT AND CFO",
        "authorized_official_telephone_number": "843-777-2910",
        "authorized_official_name_suffix": "III"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "McLeod Family Medicine-Timmonsville",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "McLeod Family Medicine-Timmonsville",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Timmonsville, SC

Sources for this page

Verify at the official NPI Registry.