MEDICARE: KEVIN R MCCLELLAN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	036061120	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	16202167	OTHER	IL	BCBS NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1699835249
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN R MCCLELLAN MD

Provider Business Mailing Address
First Line	:	7421 N MILWAUKEE AVE
Second Line	:
City	:	NILES
State	:	IL
Zip	:	60714-3707
Country	:	US
Telephone Number	:	773-993-0279
Fax Number	:

Provider Business Practice Location Address
First Line	:	7421 N MILWAUKEE AVE
Second Line	:
City	:	NILES
State	:	IL
Zip	:	60714-3707
Country	:	US
Telephone Number	:	773-775-0811
Fax Number	:	773-819-7013

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/12/2006
Last Update Date	:	04/24/2023

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