Basic Information
| Provider Information | |||||||||
| NPI: | 1245217363 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCLEAN | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 455 SHERMAN ST | ||||||||
| Address2: | STE 510 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802034400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033776825 | ||||||||
| FaxNumber: | 3037800787 | ||||||||
| Practice Location | |||||||||
| Address1: | 455 SHERMAN | ||||||||
| Address2: | SUITE 510 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802034405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033776825 | ||||||||
| FaxNumber: | 3037800787 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2005 | ||||||||
| LastUpdateDate: | 06/28/2012 | ||||||||
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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 | 207L00000X | 26141 | CO | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 7612563 | 05 | NC | MEDICAID | 82622200 | 05 | WI | MEDICAID | 01261411 | 05 | CO | MEDICAID | 3506685 | 05 | MT | MEDICAID | 100121110A | 05 | KS | MEDICAID | 84113438513 | 05 | NE | MEDICAID | L4939 | 05 | NM | MEDICAID | 051284001 | 05 | TX | MEDICAID | XPY203733 | 05 | CA | MEDICAID | 109201400 | 05 | WY | MEDICAID |