Provider Demographics
NPI:1518060169
Name:MCLAIN, MYRTLE (MD)
Entity Type:Individual
Prefix:MS
First Name:MYRTLE
Middle Name:
Last Name:MCLAIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 S SULLIVAN AVE
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:MI
Mailing Address - Zip Code:49412-1548
Mailing Address - Country:US
Mailing Address - Phone:231-854-6415
Mailing Address - Fax:231-854-6975
Practice Address - Street 1:78 N DIVISION
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:MI
Practice Address - Zip Code:49421
Practice Address - Country:US
Practice Address - Phone:231-854-6415
Practice Address - Fax:231-854-6975
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301027718207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301027718OtherSTATE LICENSE NUMBER