Provider Demographics
NPI:1619036498
Name:MCLEAN & D G CLINIC
Entity Type:Organization
Organization Name:MCLEAN & D G CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCLEAN
Authorized Official - Suffix:
Authorized Official - Credentials:ANP
Authorized Official - Phone:870-777-0007
Mailing Address - Street 1:104 E 16TH ST
Mailing Address - Street 2:
Mailing Address - City:HOPE
Mailing Address - State:AR
Mailing Address - Zip Code:71801-7424
Mailing Address - Country:US
Mailing Address - Phone:870-777-0007
Mailing Address - Fax:870-777-0061
Practice Address - Street 1:104 E 16TH ST
Practice Address - Street 2:
Practice Address - City:HOPE
Practice Address - State:AR
Practice Address - Zip Code:71801-7424
Practice Address - Country:US
Practice Address - Phone:870-777-0007
Practice Address - Fax:870-777-0061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-07
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01251173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR102612001Medicaid
AR5T414OtherARKANSAS BCBS
AR14169000002OtherQUALCHOICE
AR14169000002OtherQUALCHOICE