Provider Demographics
NPI:1184843682
Name:MCCLINTOCK, TRAVIS WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:WAYNE
Last Name:MCCLINTOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1535 GULL RD
Mailing Address - Street 2:MSB 015
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-1650
Mailing Address - Country:US
Mailing Address - Phone:269-226-6933
Mailing Address - Fax:269-226-6949
Practice Address - Street 1:1535 GULL RD
Practice Address - Street 2:MSB 015
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1650
Practice Address - Country:US
Practice Address - Phone:269-226-6933
Practice Address - Fax:269-226-6949
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301084373207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI105190445Medicaid
MITM084373OtherBLUE CROSS BLUE SHIELD
MI0G56008OtherMEDICARE GROUP-TR HEALTH
MI700G560080OtherBCBS GROUP-THREE RIVERS HEALTH
MIG56008153Medicare PIN
MI700G560080OtherBCBS GROUP-THREE RIVERS HEALTH
MITM084373OtherBLUE CROSS BLUE SHIELD
MI230015Medicare Oscar/Certification