=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093763542
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GREGORY DEWAYNE MCCLAIN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2006
-----------------------------------------------------
Last Update Date | 10/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1020 LAKEVIEW AVE
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81004-3508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-557-3777
-----------------------------------------------------
Fax | 719-557-3775
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 800022
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64180-0022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-953-0104
-----------------------------------------------------
Fax | 303-765-6670
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 2013025596
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | ME101924
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | DR.0055743
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | DR.0055743
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 1489-TEP
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | N3408
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------