Healthcare Provider Details

I. General information

NPI: 1851557698
Provider Name (Legal Business Name): PHILIP MCCLARTY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2008
Last Update Date: 09/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 EVERGREEN DR NE
GRAND RAPIDS MI
49525-9493
US

IV. Provider business mailing address

3333 EVERGREEN DR NE
GRAND RAPIDS MI
49525-9493
US

V. Phone/Fax

Practice location:
  • Phone: 616-364-4200
  • Fax: 616-364-7347
Mailing address:
  • Phone: 616-364-4200
  • Fax: 616-364-7347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301092378
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number4301092378
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number29826
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: