Basic Information
Provider Information | |||||||||
NPI: | 1932302866 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCLEAN | ||||||||
FirstName: | KEVIN | ||||||||
MiddleName: | W. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 198207 | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303848207 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8006344064 | ||||||||
FaxNumber: | 9525136880 | ||||||||
Practice Location | |||||||||
Address1: | 1295 ORANGE AVENUE | ||||||||
Address2: |   | ||||||||
City: | WINTER PARK | ||||||||
State: | FL | ||||||||
PostalCode: | 327894984 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4076285051 | ||||||||
FaxNumber: | 4076296096 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/07/2007 | ||||||||
LastUpdateDate: | 10/29/2012 | ||||||||
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 | 2085R0202X | ME109286 | FL | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.