Healthcare Provider Details

I. General information

NPI: 1457404865
Provider Name (Legal Business Name): KEN RONALD MCCLAIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1232 UNIVERSITY OF OREGON
EUGENE OR
97403-1205
US

IV. Provider business mailing address

1232 UNIVERSITY OF OREGON
EUGENE OR
97403-1205
US

V. Phone/Fax

Practice location:
  • Phone: 541-346-2751
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD20555
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier150484
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: