Provider Demographics
NPI:1003850918
Name:MCCLELLAND, KEVIN J (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:MCCLELLAND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 MAPLE LN
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806-3610
Mailing Address - Country:US
Mailing Address - Phone:715-685-5500
Mailing Address - Fax:715-685-5118
Practice Address - Street 1:1615 MAPLE LN
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-3610
Practice Address - Country:US
Practice Address - Phone:715-685-5290
Practice Address - Fax:715-685-5118
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33292207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
521359OtherPTAN
WI31836700Medicaid
WI000004023Medicare PIN
WI31836700Medicaid
K400265058Medicare PIN