Healthcare Provider Details

I. General information

NPI: 1801845078
Provider Name (Legal Business Name): BRIAN MCCLENIC MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 04/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8317 CALUMET AVE
MUNSTER IN
46321-1737
US

IV. Provider business mailing address

8317 CALUMET AVE
MUNSTER IN
46321-1737
US

V. Phone/Fax

Practice location:
  • Phone: 219-513-2333
  • Fax: 219-513-2334
Mailing address:
  • Phone: 219-513-2333
  • Fax: 219-513-2334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number01051695A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number01051695A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number01051695
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: