Provider Demographics
NPI:1033139399
Name:MACLEAN, MICHAEL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:MACLEAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:676 N SAINT CLAIR ST
Mailing Address - Street 2:SUITE 850
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2927
Mailing Address - Country:US
Mailing Address - Phone:312-695-4526
Mailing Address - Fax:312-695-6189
Practice Address - Street 1:676 N SAINT CLAIR ST
Practice Address - Street 2:SUITE 850
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2927
Practice Address - Country:US
Practice Address - Phone:312-695-4526
Practice Address - Fax:312-695-6189
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK15322Medicare ID - Type Unspecified