NPIMap

Organization Active NPI

McLeod Medical Center-Dillon

  • Medicare Defined Swing Bed Hospital Unit
  • Dillon, SC
National Provider Identifier
1124487541
Registry record updated May 22, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Medicare Defined Swing Bed Hospital UnitTaxonomy code 275N00000X
License
HTL-0631 Issued in SC
Legal business name
MCLEOD MEDICAL CENTER-DILLON
Practice address
301 E Jackson St
Dillon, SC 29536-2509
Phone
(843) 774-4111
NPI assigned
Feb 12, 2016
Last updated
May 22, 2019By the provider in NPPES
Organization subpart
Yes
Parent organization
MCLEOD HEALTHAs reported in NPPES

NPPES NPI Registry

Updated by the provider on May 22, 2019

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

Authorized official

Name
Mr. Samuel Fulton Ervin III
Title
Sr. VP & Cfo
Phone
(843) 777-2910

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Medicare Defined Swing Bed Hospital Unit 275N00000X HTL-0631 SC Primary

Addresses

Primary practice location

301 E Jackson St
Dillon, SC 29536-2509

Mailing address

301 E Jackson St
Dillon, SC 29536-2509

Other identifiers 3

IdentifierTypeStateIssuer
C046NFMedicaidSC
0854SBMedicaidSC
42U005OtherSCMEDICARE ID

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in SC

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20160331001727 SC Part A Provider - Hospital 3476465311 Practice locations: Dillon, SC

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1124487541. Details of each certification follow.

Hospital certification: CCN 42U005

Legal name
MCLEOD MEDICAL CENTER-DILLON
Organization structure
CorporationNon-profit
Incorporated
Jul 3, 2003 in SC
Enrollment address
301 E Jackson St
Dillon, SC 29536-2509
Other Hospital Practice Location
Hospital subgroups
Swing-bed approved

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 2

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

National Provider Directory

National Provider Directory
Tax ID family
McLeod Medical Center Dillon3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

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

Ownership & related parties

All disclosed owners & managing parties 30

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 Feb 1, 2016
J Douglas Lynn Individual Corporate OfficerBoard of Trustees Jan 1, 2026
David Oren Atkinson Individual Corporate OfficerBoard of Trustees Jan 1, 2026
Matthew Prince Individual Corporate OfficerBoard of Trustees Jan 1, 2026
Frances S Jones Individual Corporate DirectorBoard of Trustees Feb 1, 2016
Ashley Brady Individual Corporate OfficerBoard of Trustees Jan 1, 2018
William N Boulware Individual Corporate OfficerBoard of Trustees Feb 1, 2016
Shelia Rollins Individual W-2 Managing EmployeeNet Rev MGR Jan 1, 2026
John M Scott Individual Corporate OfficerBoard of Trustees Jan 1, 2026
Christian Soura Individual Corporate OfficerSr VP & Cfo Jan 1, 2026
Ronald M Fowler Individual Corporate OfficerBoard of Trustees Feb 1, 2016
Dudley B. Harrington Individual Corporate OfficerVP of Business Operations Jan 1, 2018
Virginia L Clyburn-Ipock Individual Corporate OfficerBoard of Trustees Jun 1, 2021
Jeannette Glenn Individual Corporate OfficerBoard of Trustees Jan 1, 2018
McLeod Health Organization, Florence, SC Non-profit 5% Or Greater Direct Ownership Interest Jul 3, 2003 100%
Samuel F Ervin Individual Corporate OfficerSr. Vice President and Cfo Feb 1, 2016
Marwan Kamil Elya Individual Corporate OfficerBoard of Trustees Jan 1, 2026
Hugh S Blair Individual Corporate OfficerBoard of Trustees Jan 1, 2018
Mary Anderson Individual Corporate OfficerBoard of Trustees Jan 1, 2018
Tracy Ray Individual Corporate OfficerBoard of Trustees Feb 1, 2016
Virginia Hardee Individual W-2 Managing EmployeeAd; Jan 1, 2026
Donna Isgett Individual Corporate OfficerPresident and Ceo Mar 1, 2021
Tarek M Bishara Individual Corporate OfficerBoard of Trustees Jan 1, 2018
Beverly Hazelwood Individual Corporate OfficerBoard of Trustees Jan 1, 2018
Amy Fisher Individual Corporate Officer Jun 1, 2021
Amit Vyankatesh Pande Individual Corporate OfficerBoard of Trustees Jun 1, 2021
Frank V Boulineau Individual Corporate OfficerBoard of Trustees Feb 1, 2016
Patrick Kerry Denton Individual Corporate OfficerBoard of Trustees Jan 1, 2018
Frank J Brand Individual Corporate OfficerBoard of Trustees Feb 1, 2016
James C Smith Individual Corporate OfficerBoard of Trustees Jan 1, 2021

Owners & managing parties with NPI records 9

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

Practitioners & affiliated clinicians

Practitioners 115

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 115

NPI Registry JSON

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

{
    "created_epoch": "1455235200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1558483200000",
    "number": "1124487541",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "301 E JACKSON ST",
            "city": "DILLON",
            "state": "SC",
            "postal_code": "295362509"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "301 E JACKSON ST",
            "city": "DILLON",
            "state": "SC",
            "postal_code": "295362509",
            "telephone_number": "843-774-4111"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MCLEOD MEDICAL CENTER-DILLON",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MCLEOD HEALTH",
        "enumeration_date": "2016-02-12",
        "last_updated": "2019-05-22",
        "status": "A",
        "authorized_official_last_name": "ERVIN",
        "authorized_official_first_name": "SAMUEL",
        "authorized_official_middle_name": "FULTON",
        "authorized_official_title_or_position": "SR. VP & CFO",
        "authorized_official_telephone_number": "843-777-2910",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_name_suffix": "III"
    },
    "taxonomies": [
        {
            "code": "275N00000X",
            "taxonomy_group": "",
            "desc": "Medicare Defined Swing Bed Unit",
            "state": "SC",
            "license": "HTL-0631",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "C046NF",
            "state": "SC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0854SB",
            "state": "SC"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE ID",
            "identifier": "42U005",
            "state": "SC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Dillon, SC

Sources for this page

Verify at the official NPI Registry.