Provider Demographics
NPI:1114260122
Name:MCLEAN, TAM PHAM
Entity Type:Individual
Prefix:
First Name:TAM
Middle Name:PHAM
Last Name:MCLEAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7590 AUBURN ROAD, SUITE 014
Mailing Address - Street 2:ATTN: MED STAFF
Mailing Address - City:CONCORD TWP
Mailing Address - State:OH
Mailing Address - Zip Code:44077-9176
Mailing Address - Country:US
Mailing Address - Phone:440-354-1899
Mailing Address - Fax:440-354-1845
Practice Address - Street 1:5105 SOM CENTER RD
Practice Address - Street 2:#106
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-4203
Practice Address - Country:US
Practice Address - Phone:440-953-5740
Practice Address - Fax:440-953-5741
Is Sole Proprietor?:No
Enumeration Date:2013-03-28
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.127316207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH'0190167Medicaid
OHH585701Medicare PIN