Healthcare Provider Details

I. General information

NPI: 1669463436
Provider Name (Legal Business Name): SCOTT WILLIAM MCLAIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 07/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 E COLLEGE AVE
BLOOMINGTON IL
61704
US

IV. Provider business mailing address

5850 6TH STREET FRONTAGE RD E
SPRINGFIELD IL
62703-5162
US

V. Phone/Fax

Practice location:
  • Phone: 309-662-5361
  • Fax: 309-663-5742
Mailing address:
  • Phone: 217-529-5046
  • Fax: 217-529-6154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2007006527
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036104057
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: