Provider Demographics
NPI:1770659062
Name:MCCLELLAN, ELIZABETH A (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:MCCLELLAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 ALEX LN
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-2952
Mailing Address - Country:US
Mailing Address - Phone:304-734-2040
Mailing Address - Fax:304-734-2047
Practice Address - Street 1:107 KOONTZ AVE STE 200
Practice Address - Street 2:
Practice Address - City:CLENDENIN
Practice Address - State:WV
Practice Address - Zip Code:25045-9581
Practice Address - Country:US
Practice Address - Phone:304-548-7272
Practice Address - Fax:304-548-7149
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV219412084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810003270Medicaid
WV0005355002Medicaid
WVI35290Medicare UPIN
WVMC4164361Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
WV3810003270Medicaid