NPIMap

Organization Active NPI

McLeod Health Clarendon

Doing business as McLeod Family Medicine-Johnsonville

  • Rural Health Clinic/Center
  • Johnsonville, SC
National Provider Identifier
1144875774
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-Johnsonville
Practice address
355 S Georgetown Hwy
Johnsonville, SC 29555-8083
Phone
(843) 380-2000
NPI assigned
Aug 9, 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 3

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X NU
Rural Health Clinic/Center 261QR1300X NU Primary
Family Nurse Practitioner 363LF0000X NU

Addresses

Primary practice location

355 S Georgetown Hwy
Johnsonville, SC 29555-8083

Mailing address

PO Box 100567
Florence, SC 29502-0567

Other identifiers 3

IdentifierTypeStateIssuer
GP2568MedicaidSC
42-8989OtherSCPTAN
RHC176MedicaidSC

Other names 1

  • McLeod Family Medicine-Johnsonville 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
O20190910000321 SC Part A Provider - Rural Health Clinic 0840582656 Practice locations: Johnsonville, SC

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1144875774. Details of each certification follow.

Rural health clinic certification: CCN 423467

Legal name
MCLEOD HEALTH CLARENDON
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Dec 8, 2019
Last certification
Oct 30, 2023
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
May 27, 2016 in SC
Enrollment address
355 S Georgetown Hwy
Johnsonville, SC 29555-8083
Related CCNs
420051

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

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

355 S Georgetown Hwy
Johnsonville, SC 29555
Phone (843) 380-2000

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

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 1, 2019 Change of OwnershipThis provider was the buyer McLeod Family Medicine - JohnsonvilleCCN 428989, SC, NPI 1912001645

Change of ownership 1

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

Practitioners & affiliated clinicians

Practitioners 12

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.

NPI Registry JSON

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

{
    "created_epoch": "1565308800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1565740800000",
    "number": "1144875774",
    "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": "355 S GEORGETOWN HWY",
            "city": "JOHNSONVILLE",
            "state": "SC",
            "postal_code": "295558083",
            "telephone_number": "843-380-2000"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MCLEOD HEALTH CLARENDON",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-08-09",
        "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": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "GP2568",
            "state": "SC"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PTAN",
            "identifier": "42-8989",
            "state": "SC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "RHC176",
            "state": "SC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "McLeod Family Medicine-Johnsonville",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "McLeod Family Medicine-Johnsonville",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Johnsonville, SC

Sources for this page

Verify at the official NPI Registry.