NPIMap

McLeod Health Clarendon

Organization Active NPI Rural Health Clinic/Center · Timmonsville, SC

NPI 1003461773 · NPPES record last updated Aug 14, 2019

Key facts

NPI
1003461773
Entity type
Organization (NPI type 2)
Primary specialty
Rural Health Clinic/Center 261QR1300X
Legal business name
MCLEOD HEALTH CLARENDON
Practice address
755 E Smith St
Timmonsville, SC 29161-9430
Phone
(843) 346-3900
NPI assigned
Aug 8, 2019
Organization subpart
No

Authorized official

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

Owners & managing parties with NPI records 7

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

Other NPIs on the same Medicare enrollment 6

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

Other NPIs with the same Medicare PAC ID 8

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

Corporate family (same tax ID) 8

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

Change of ownership 1

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

Facilities with the same owner 17

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

Practitioners 231

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 231

Medicare participation

Medicare fee-for-service enrollment
Enrolled (2 enrollments) in SC

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
Corporation · Non-profit
Incorporated
May 27, 2016 in SC
Enrollment address
755 E Smith St
Timmonsville, SC 29161-9430
Related CCNs
42D0929081

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 Officer
Board of Trustees		 Jul 12, 2016
Vinod K Jona
Individual 		Corporate Officer
Board of Trustees		 Jan 1, 2021
Steven R Ross
Individual 		Corporate Officer
Board of Directors		 Jul 12, 2016
Rachel T Gainey
Individual 		W-2 Managing Employee
VP/Administrator		 Jul 12, 2016
Frances S Jones
Individual 		Corporate Officer
Board of Directors		 Jul 12, 2016
Ashley Brady
Individual 		Corporate Officer
Board of Directors		 Jul 12, 2019
William N Boulware
Individual 		Corporate Officer
Board of Directors		 Jul 12, 2016
Allie E Brooks
Individual 		Corporate Officer
Board of Directors		 Jul 12, 2016
Benjamin T Zeigler
Individual 		Corporate Officer
Board of Directors		 Jul 12, 2016
Ronald M Fowler
Individual 		Corporate Officer
Board of Directors		 Jul 12, 2016
Dudley B. Harrington
Individual 		Corporate Officer
VP of Business Operations		 Jul 12, 2016
Jeannette Glenn
Individual 		Corporate Officer
Board 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 Officer
Senior VP and Cfo		 Jul 12, 2016
Raymond Clark
Individual 		Corporate Officer
Board of Directors		 Jul 12, 2016
Hugh S Blair
Individual 		Corporate Officer
Board of Directors		 Jul 12, 2016
Mary Anderson
Individual 		Corporate Officer
Board of Directors		 Jul 16, 2016
Tracy Ray
Individual 		Corporate Officer
Board of Directors		 Jul 12, 2016
Donna Isgett
Individual 		Corporate Officer
Board of Trustees		 Mar 1, 2021
Tarek M Bishara
Individual 		Corporate Officer
Board of Directors		 Jul 12, 2016
Beverly Hazelwood
Individual 		Corporate Officer
Board of Directors		 Jul 12, 2016
Frank V Boulineau
Individual 		Corporate Officer
Board of Directors		 Jul 12, 2016
Michael R Rose
Individual 		Corporate Officer
Board of Directors		 Jul 12, 2016
Patrick Kerry Denton
Individual 		Corporate Officer
Board of Directors		 Jul 12, 2016
Frank J Brand
Individual 		Corporate Officer
Board of Directors		 Jul 12, 2016
James C Smith
Individual 		Corporate Officer
Board of Directors		 Jul 12, 2016
John R Braddy
Individual 		Corporate Officer
Board of Directors		 Jul 12, 2016

Change-of-ownership history

DateEventCounterparty
Aug 15, 2019 Change of Ownership
This provider was the buyer		 McLeod Family Practice Timmonsville
CCN 428962 · SC · NPI 1528162112

Medicare enrollment records

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

National Provider Directory

Tax ID family
McLeod Health Clarendon (9 organizations share this tax ID)

Specialties & licenses

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

Addresses

Primary practice location

755 E Smith St
Timmonsville, SC 29161-9430

Mailing address

PO Box 100567
Florence, SC 29502-0567

Other identifiers

IdentifierTypeStateIssuer
RHC137MedicaidSC
GP1781MedicaidSC
42-8962OtherSCPTAN
RHC170MedicaidSC

Other names

  • McLeod Family Medicine-Timmonsville Doing business as

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Aug 14, 2019.

{
    "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": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "RHC137",
            "state": "SC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "GP1781",
            "state": "SC"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PTAN",
            "identifier": "42-8962",
            "state": "SC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "RHC170",
            "state": "SC"
        }
    ],
    "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

All providers in Timmonsville, SC · Rural Health Clinic/Center in South Carolina

Sources for this page

Verify at the official NPI Registry.