NPIMap

Organization Active NPI

McLeod Health Clarendon

  • Rural Health Clinic/Center
  • Manning, SC
National Provider Identifier
1962851097
Registry record updated Apr 17, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
MCLEOD HEALTH CLARENDON
Practice address
200 E Hospital St
Manning, SC 29102-3160
Phone
(803) 433-0439
NPI assigned
Jun 9, 2016
Organization subpart
Yes
Parent organization
MCLEOD HEALTHAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Apr 17, 2020

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 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

200 E Hospital St
Manning, SC 29102-3160

Mailing address

200 E Hospital St
Manning, SC 29102-3160
Phone (803) 433-0439

Other identifiers 2

IdentifierTypeStateIssuer
RHC242MedicaidSC
87-3801OtherSCMEDICARE

Other names 2

  • Eagerton Family Medicine Doing business as
  • McLeod Family Medicine-Dr. Eagerton, Jr. Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20160808002187 SC Part A Provider - Rural Health Clinic 0840582656 Practice locations: Manning, SC
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

Rural health clinic certification: CCN 423471

Legal name
MCLEOD HEALTH CLARENDON
Doing business as
EAGERTON FAMILY PRACTICE
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Mar 1, 2019
Last certification
Sep 3, 2024
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
May 27, 2016 in SC
Enrollment address
200 E Hospital St
Manning, SC 29102-3160
Related CCNs
420109

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

50 E Hospital St
Ste 2
Manning, SC 29102
Phone (803) 433-0797

Ownership & related parties

All disclosed owners & managing parties 31

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
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 OfficerBoard of Trustees Jul 12, 2016
Ashley Brady Individual Corporate OfficerBoard of Trustees Jan 1, 2021
William N Boulware Individual Corporate OfficerBoard of Trustees Jul 12, 2016
Allie E Brooks Individual Corporate OfficerBoard of Trustees Jan 1, 2021
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 Jul 12, 2016
Dudley B. Harrington Individual Corporate OfficerVP of Business Operations Jan 1, 2026
Virginia L Clyburn-Ipock Individual Corporate OfficerBoard of Directors Jan 1, 2026
Jeannette Glenn Individual Corporate OfficerBoard of Trustees Jan 1, 2021
McLeod Health Organization, Florence, SC Corporation, Non-profit 5% Or Greater Direct Ownership Interest Jul 12, 2016 100%
Samuel F Ervin Individual Corporate OfficerSr VP & Cfo Jul 12, 2016
Jeffrey Scott Adams Individual W-2 Managing EmployeeAd; Mar 2, 2026
Marwan Kamil Elya Individual Corporate OfficerBoard of Trustees Jan 1, 2026
Hugh S Blair Individual Corporate OfficerBoard of Trustees Jan 1, 2021
Mary Anderson Individual Corporate DirectorBoard of Trustees Jul 12, 2016
Tracy Ray Individual Corporate OfficerBoard of Trustees Jul 12, 2016
Donna Isgett Individual Corporate OfficerBoard of Trustees Mar 1, 2021
Tarek M Bishara Individual Corporate OfficerBoard of Trustees Jan 1, 2021
Beverly Hazelwood Individual Corporate OfficerBoard of Trustees Jan 1, 2021
Amy Fisher Individual Corporate OfficerBoard of Trustees Jan 1, 2026
Amit Vyankatesh Pande Individual Corporate OfficerBoard of Trustees Jan 1, 2026
Frank V Boulineau Individual Corporate OfficerBoard of Trustees Jul 12, 2016
Patrick Kerry Denton Individual Corporate OfficerBoard of Trustees Jan 1, 2021
Frank J Brand Individual Corporate OfficerBoard of Trustees Jul 12, 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 12

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

NPI Registry JSON

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

{
    "created_epoch": "1465430400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1587081600000",
    "number": "1962851097",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "200 E HOSPITAL ST",
            "city": "MANNING",
            "state": "SC",
            "postal_code": "291023160",
            "telephone_number": "803-433-0439"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "200 E HOSPITAL ST",
            "city": "MANNING",
            "state": "SC",
            "postal_code": "291023160",
            "telephone_number": "803-433-0439"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MCLEOD HEALTH CLARENDON",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MCLEOD HEALTH",
        "enumeration_date": "2016-06-09",
        "last_updated": "2020-04-17",
        "certification_date": "2020-04-17",
        "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_prefix": "Mr.",
        "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": "RHC242",
            "state": "SC"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE",
            "identifier": "87-3801",
            "state": "SC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Eagerton Family Medicine",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "McLeod Family Medicine-Dr. Eagerton, Jr.",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Manning, SC

Sources for this page

Verify at the official NPI Registry.