Basic Information
Provider Information | |||||||||
NPI: | 1467677914 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCCLUNE | ||||||||
FirstName: | JASON | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4700 WATERS AVE STE 507 | ||||||||
Address2: |   | ||||||||
City: | SAVANNAH | ||||||||
State: | GA | ||||||||
PostalCode: | 31404 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9123504750 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4700 WATERS AVE STE 507 | ||||||||
Address2: |   | ||||||||
City: | SAVANNAH | ||||||||
State: | GA | ||||||||
PostalCode: | 31404 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9123504750 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/17/2007 | ||||||||
LastUpdateDate: | 11/27/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 31624 | SC | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | MD451257 | PA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RP1001X | MD451257 | PA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 208M00000X | MD451257 | PA | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 207RP1001X | 064678 | GA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
ID | Type | State | Issuer | Description | 452897 | 01 | PA | MEDICARE | OTHER | 103064425 | 05 | PA |   | MEDICAID |