MEDICARE: MS. MICHELLE MARLENE MCCLAIN

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	174400000X	Specialist	13993	MT

General Provider Information

NPI Number	:	1912132481
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MICHELLE MARLENE MCCLAIN

Provider Business Mailing Address
First Line	:	2409 DEARBORN AVE STE I
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59801-7586
Country	:	US
Telephone Number	:	406-549-0777
Fax Number	:	406-549-0386

Provider Business Practice Location Address
First Line	:	2409 DEARBORN AVE STE I
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59801-7586
Country	:	US
Telephone Number	:	406-549-0777
Fax Number	:	406-549-0386

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

Provider Enumeration Date	:	05/27/2009
Last Update Date	:	05/27/2009

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