=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417051053
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DENNIS ROBERT MCCLAIN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2006
-----------------------------------------------------
Last Update Date | 08/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3605 NORTHGATE CT STE 110
-----------------------------------------------------
City | NEW ALBANY
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47150-6400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-949-5749
-----------------------------------------------------
Fax | 812-929-5794
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 776351
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60677-6351
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-588-9490
-----------------------------------------------------
Fax | 502-272-5116
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 01030085A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2083X0100X
-----------------------------------------------------
Taxonomy Name | Occupational Medicine Physician
-----------------------------------------------------
License Number | 01030085A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------