Healthcare Provider Details

I. General information

NPI: 1740368901
Provider Name (Legal Business Name): GAIL K MCCLAVE MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 05/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 ELMIRA AVE SE SUITE 103
BANDON OR
97411-7405
US

IV. Provider business mailing address

PO BOX 393
BANDON OR
97411
US

V. Phone/Fax

Practice location:
  • Phone: 541-347-2111
  • Fax: 541-347-1212
Mailing address:
  • Phone: 541-347-2111
  • Fax: 541-347-1212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: GAIL KOCH MCCLAVE
Title or Position: OWNER
Credential: MD
Phone: 541-347-2111