Basic Information
| Provider Information | |||||||||
| NPI: | 1336180744 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCLUNG | ||||||||
| FirstName: | JASON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 156 WEST AVE | ||||||||
| Address2: | EMERGENCY DEPARTMENT | ||||||||
| City: | BROCKPORT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 144201229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853956095 | ||||||||
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| Practice Location | |||||||||
| Address1: | 156 WEST AVE | ||||||||
| Address2: | EMERGENCY DEPARTMENT | ||||||||
| City: | BROCKPORT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 144201229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853956095 | ||||||||
| FaxNumber: | 5853956017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 02/13/2009 | ||||||||
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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 | 207P00000X | 230745 | NY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 230745-2 EM | 01 | NY | WORKER'S COMPENSATION | OTHER | 02568514 | 05 | NY | MEDICAID |