MEDICARE: DR. STACEY DALE MCCLURE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician	34081	AZ
2	207X00000X	Orthopaedic Surgery Physician	34081	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700814639
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STACEY DALE MCCLURE M.D.

Provider Business Mailing Address
First Line	:	2730 W AGUA FRIA FWY STE 103
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85027-7202
Country	:	US
Telephone Number	:	480-699-2472
Fax Number	:	480-699-4372

Provider Business Practice Location Address
First Line	:	2730 W AGUA FRIA FWY STE 103
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85027-7202
Country	:	US
Telephone Number	:	480-699-2472
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/29/2006
Last Update Date	:	07/09/2020

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