Healthcare Provider Details

I. General information

NPI: 1427046366
Provider Name (Legal Business Name): MARTIN BARRY MCCLINTOCK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 05/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15421 CLAYTON RD SUITE G-2
BALLWIN MO
63011-3161
US

IV. Provider business mailing address

15421 CLAYTON RD SUITE G-2
BALLWIN MO
63011-3161
US

V. Phone/Fax

Practice location:
  • Phone: 636-227-2707
  • Fax: 636-227-1216
Mailing address:
  • Phone: 636-227-2707
  • Fax: 636-227-1216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR7737
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: