Provider Demographics
NPI:1710974472
Name:MCCLELLAN, JOHN B III (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:B
Last Name:MCCLELLAN
Suffix:III
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 1:5540 W 111TH ST
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-5574
Mailing Address - Country:US
Mailing Address - Phone:708-423-8440
Mailing Address - Fax:708-658-2962
Practice Address - Street 1:5540 W 111TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-5574
Practice Address - Country:US
Practice Address - Phone:708-423-8440
Practice Address - Fax:708-658-2962
Is Sole Proprietor?:No
Enumeration Date:2005-09-28
Last Update Date:2021-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036055747207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01623030OtherBCBS
IL036055747Medicaid
ILF400279788OtherMEDICARE PTAN -SPI
ILF400279788OtherMEDICARE PTAN -SPI