1801845078 NPI number — BRIAN MCCLENIC MD

Table of content: BRIAN MCCLENIC MD (NPI 1801845078)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801845078 NPI number — BRIAN MCCLENIC MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCLENIC
Provider First Name:
BRIAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1801845078
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/07/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8317 CALUMET AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MUNSTER
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46321-1737
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-513-2333
Provider Business Mailing Address Fax Number:
219-513-2334

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8317 CALUMET AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MUNSTER
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46321-1737
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-513-2333
Provider Business Practice Location Address Fax Number:
219-513-2334
Provider Enumeration Date:
05/08/2006

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: 207L00000X , with the licence number:  01051695A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LP2900X , with the licence number: 01051695A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0014X , with the licence number: 01051695 , 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: 000000494372 . This is a "ANTHEM BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200251340A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000573813 . This is a "ANTHEM BC/BS OF INDIANA" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 036085894 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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