Healthcare Provider Details

I. General information

NPI: 1518189174
Provider Name (Legal Business Name): MICHAEL J CLEGG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 07/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

WHMC 2200 BERGQUIST DRIVE, SUITE 1
LACKLAND AIR FORCE BASE TX
78236-5300
US

IV. Provider business mailing address

55 WESTPORT PLAZA DR. SUITE 300
ST. LOUIS MO
63146-5300
US

V. Phone/Fax

Practice location:
  • Phone: 210-292-7667
  • Fax:
Mailing address:
  • Phone: 314-548-4715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number23957
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number23957
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: