Basic Information
| Provider Information | |||||||||
| NPI: | 1013004548 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCLURE | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 BRYANT WILLIAMS DR FL 2 | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976011121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418833391 | ||||||||
| FaxNumber: | 5418832250 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 BRYANT WILLIAMS DR FL 2 | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976011121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418833391 | ||||||||
| FaxNumber: | 5418832250 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | MD11222 | OR | X | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085U0001X | MD11222 | OR | X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 208600000X | MD11222 | OR | X | Allopathic & Osteopathic Physicians | Surgery | 2086S0102X | MD11222 | OR | X | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0120X | MD11222 | OR | X | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery | 2086S0127X | MD11222 | OR | X | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 2086S0129X | MD11222 | OR | X | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208800000X | MD11222 | OR | X | Allopathic & Osteopathic Physicians | Urology | 2088P0231X | MD11222 | OR | X | Allopathic & Osteopathic Physicians | Urology | Pediatric Urology | 208C00000X | MD11222 | OR | X | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery | 208G00000X | MD11222 | OR | X | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | USA238530 | 05 | CA | MEDICAID | 006213 | 05 | OR | MEDICAID |