1619036498 NPI number — MCLEAN & D G CLINIC

Table of content: (NPI 1619036498)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619036498 NPI number — MCLEAN & D G CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MCLEAN & D G CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1619036498
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 E 16TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOPE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71801-7424
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-777-0007
Provider Business Mailing Address Fax Number:
870-777-0061

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 E 16TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOPE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71801-7424
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-777-0007
Provider Business Practice Location Address Fax Number:
870-777-0061
Provider Enumeration Date:
12/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCLEAN
Authorized Official First Name:
JOAN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
NURSE PRACTIONER
Authorized Official Telephone Number:
870-777-0007

Provider Taxonomy Codes

  • Taxonomy code: 173000000X , with the licence number:  A01251 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 102612001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5T414 . This is a "ARKANSAS BCBS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 14169000002 . This is a "QUALCHOICE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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