Provider Demographics
NPI:1699835249
Name:MCCLELLAN, KEVIN R (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:R
Last Name:MCCLELLAN
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 1:7421 N MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-3707
Mailing Address - Country:US
Mailing Address - Phone:773-993-0279
Mailing Address - Fax:
Practice Address - Street 1:7421 N MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-3707
Practice Address - Country:US
Practice Address - Phone:773-775-0811
Practice Address - Fax:773-819-7013
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036061120207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL16202167OtherBCBS NUMBER
IL036061120Medicaid
IL16202167OtherBCBS NUMBER
ILP07288Medicare ID - Type UnspecifiedMEDICARE NUMBER
IL58652Medicare ID - Type UnspecifiedMEDICARE RAILROAD