Basic Information
| Provider Information | |||||||||
| NPI: | 1649343310 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCLEAN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 440013 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372440013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6156202320 | ||||||||
| FaxNumber: | 6156202323 | ||||||||
| Practice Location | |||||||||
| Address1: | 1607 SOUTH LOCUST AVE | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEBURG | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6156202320 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 08/05/2010 | ||||||||
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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 | MD37375 | TN | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 01069632 | 01 | TN | AMERIGROUP TENNCARE ONLY | OTHER | 3384834 | 05 | TN | MEDICAID | 4059473 | 01 | TN | BLUE CROSS/BLUE SHIELD OF TN | OTHER |