Basic Information
| Provider Information | |||||||||
| NPI: | 1164408886 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCLELLAN | ||||||||
| FirstName: | RICKEY | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2917 | ||||||||
| Address2: | |||||||||
| City: | PIKEVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 415022917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6062181000 | ||||||||
| FaxNumber: | 6062187507 | ||||||||
| Practice Location | |||||||||
| Address1: | 911 BYPASS RD | ||||||||
| Address2: | 7TH FLOOR CLINIC | ||||||||
| City: | PIKEVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 415011689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6062181000 | ||||||||
| FaxNumber: | 6062187507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2005 | ||||||||
| LastUpdateDate: | 08/06/2014 | ||||||||
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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 | 207V00000X | 25954 | KY | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | BM1426750 | 01 | DEA NUMBER | OTHER | 64259542 | 05 | KY | MEDICAID | 25954 | 01 | KY | MEDICAL LICENSE NUMBER | OTHER |