Provider Demographics
NPI:1790764686
Name:MCCLEW, TODD MATTHEW (CRNA)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:MATTHEW
Last Name:MCCLEW
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SAINT ELIZABETH BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1099
Mailing Address - Country:US
Mailing Address - Phone:618-234-2120
Mailing Address - Fax:
Practice Address - Street 1:1 SAINT ELIZABETH BLVD STE 104
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1099
Practice Address - Country:US
Practice Address - Phone:618-234-2120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO132185367500000X
IL209002590367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO915864417Medicaid
MO915864417Medicaid
MO000060566Medicare PIN