Provider Demographics
NPI:1689762189
Name:MCLELLAND, BRUCE A (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:A
Last Name:MCLELLAND
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 1:5401 N KNOXVILLE AVE STE 115
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5068
Mailing Address - Country:US
Mailing Address - Phone:309-691-2903
Mailing Address - Fax:309-691-2909
Practice Address - Street 1:5401 N KNOXVILLE AVE
Practice Address - Street 2:SUITE 115
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5098
Practice Address - Country:US
Practice Address - Phone:309-691-2903
Practice Address - Fax:309-691-2909
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036056311207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036056311Medicaid
ILP05833OtherPTAN
IL678830Medicare ID - Type Unspecified
ILC45095Medicare UPIN