Basic Information
| Provider Information | |||||||||
| NPI: | 1619036498 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCLEAN & D G CLINIC | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 104 E 16TH ST | ||||||||
| Address2: | |||||||||
| City: | HOPE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 718017424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707770007 | ||||||||
| FaxNumber: | 8707770061 | ||||||||
| Practice Location | |||||||||
| Address1: | 104 E 16TH ST | ||||||||
| Address2: | |||||||||
| City: | HOPE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 718017424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707770007 | ||||||||
| FaxNumber: | 8707770061 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2006 | ||||||||
| LastUpdateDate: | 06/23/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCLEAN | ||||||||
| AuthorizedOfficialFirstName: | JOAN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | NURSE PRACTIONER | ||||||||
| AuthorizedOfficialTelephone: | 8707770007 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | ANP | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173000000X | A01251 | AR | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Legal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 102612001 | 05 | AR | MEDICAID | 5T414 | 01 | AR | ARKANSAS BCBS | OTHER | 14169000002 | 01 | AR | QUALCHOICE | OTHER |