Healthcare Provider Details

I. General information

NPI: 1902223787
Provider Name (Legal Business Name): MCCLURE MEDICAL PRACTICE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2014
Last Update Date: 10/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 MAIN ST SUITE 101
WINFIELD KS
67156-3604
US

IV. Provider business mailing address

901 MAIN ST SUITE 101
WINFIELD KS
67156-3604
US

V. Phone/Fax

Practice location:
  • Phone: 620-218-1623
  • Fax: 620-402-5044
Mailing address:
  • Phone: 620-218-1623
  • Fax: 620-402-5044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number04-31220
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number04-31220
License Number StateKS

VIII. Authorized Official

Name: SHELLEY ANN MCCLURE
Title or Position: OWNER
Credential: MD
Phone: 620-218-1623