Basic Information
| Provider Information | |||||||||
| NPI: | 1710974472 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCLELLAN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5540 W 111TH ST | ||||||||
| Address2: | |||||||||
| City: | OAK LAWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604535574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084238440 | ||||||||
| FaxNumber: | 7086582962 | ||||||||
| Practice Location | |||||||||
| Address1: | 5540 W 111TH ST | ||||||||
| Address2: | |||||||||
| City: | OAK LAWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604535574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084238440 | ||||||||
| FaxNumber: | 7086582962 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2005 | ||||||||
| LastUpdateDate: | 03/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 036055747 | IL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 01623030 | 01 | IL | BCBS | OTHER | 036055747 | 05 | IL | MEDICAID | F400279788 | 01 | IL | MEDICARE PTAN -SPI | OTHER |