Basic Information
| Provider Information | |||||||||
| NPI: | 1326376872 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCLURE | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | RT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 714 N SENATE AVE | ||||||||
| Address2: | STE 100 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462023763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177156402 | ||||||||
| FaxNumber: | 3177156415 | ||||||||
| Practice Location | |||||||||
| Address1: | 714 N SENATE AVE | ||||||||
| Address2: | STE 100 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462023763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177156402 | ||||||||
| FaxNumber: | 3177156415 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2009 | ||||||||
| LastUpdateDate: | 11/20/2009 | ||||||||
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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 | 247100000X | XT018187 | IN | Y | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist |
No ID Information.