1376678862 NPI number — MR. ROBERT MCCLURG PHD

Table of content: MR. ROBERT MCCLURG PHD (NPI 1376678862)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376678862 NPI number — MR. ROBERT MCCLURG PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCLURG
Provider First Name:
ROBERT
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376678862
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/22/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 6459
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KOKOMO
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46904-6459
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-453-7422
Provider Business Mailing Address Fax Number:
765-453-3773

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
702 W ALTO RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KOKOMO
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46902-4907
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-453-7422
Provider Business Practice Location Address Fax Number:
765-453-3773
Provider Enumeration Date:
02/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  20010245A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100154150A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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