Provider Demographics
NPI:1801845078
Name:MCCLENIC, BRIAN (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:MCCLENIC
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 1:8317 CALUMET AVE
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-1737
Mailing Address - Country:US
Mailing Address - Phone:219-513-2333
Mailing Address - Fax:219-513-2334
Practice Address - Street 1:8317 CALUMET AVE
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-1737
Practice Address - Country:US
Practice Address - Phone:219-513-2333
Practice Address - Fax:219-513-2334
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01051695A207L00000X, 207LP2900X
IN01051695208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000494372OtherANTHEM BCBS
IN200251340AMedicaid
IN000000573813OtherANTHEM BC/BS OF INDIANA
IL036085894Medicaid
IL036085894Medicaid
IN256470BMedicare PIN
IN148530JMedicare PIN