Provider Demographics
NPI:1740368901
Name:GAIL K MCCLAVE MD LLC
Entity type:Organization
Organization Name:GAIL K MCCLAVE MD LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:KOCH
Authorized Official - Last Name:MCCLAVE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-347-2111
Mailing Address - Street 1:PO BOX 393
Mailing Address - Street 2:
Mailing Address - City:BANDON
Mailing Address - State:OR
Mailing Address - Zip Code:97411
Mailing Address - Country:US
Mailing Address - Phone:541-347-2111
Mailing Address - Fax:541-347-1212
Practice Address - Street 1:475 ELMIRA AVE SE
Practice Address - Street 2:SUITE 103
Practice Address - City:BANDON
Practice Address - State:OR
Practice Address - Zip Code:97411-7405
Practice Address - Country:US
Practice Address - Phone:541-347-2111
Practice Address - Fax:541-347-1212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287386Medicaid
G79392Medicare UPIN
OR287386Medicaid