Healthcare Provider Details

I. General information

NPI: 1730184359
Provider Name (Legal Business Name): GARY MARK MCCLAIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 11/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2060 DAN PROCTOR DR STE 1400
SAINT MARYS GA
31558-3894
US

IV. Provider business mailing address

2060 DAN PROCTOR DR STE 1400
SAINT MARYS GA
31558-3894
US

V. Phone/Fax

Practice location:
  • Phone: 912-576-6355
  • Fax: 912-466-6393
Mailing address:
  • Phone: 912-576-6355
  • Fax: 912-729-4654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number62569
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: