Provider Demographics
NPI:1194829457
Name:MCCLAINE, KYLE B (MD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:B
Last Name:MCCLAINE
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 1:326 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360
Mailing Address - Country:US
Mailing Address - Phone:860-889-8331
Mailing Address - Fax:
Practice Address - Street 1:326 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360
Practice Address - Country:US
Practice Address - Phone:860-889-8331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1387505207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
716689955OtherTRICARE
716689955OtherTRICARE
93000062Medicare ID - Type Unspecified