Provider Demographics
NPI:1902019649
Name:MCLEAN ORTHOPAEDICS PA
Entity Type:Organization
Organization Name:MCLEAN ORTHOPAEDICS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ROY
Authorized Official - Last Name:MCLEAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-560-2990
Mailing Address - Street 1:PO BOX 632749
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75963-2749
Mailing Address - Country:US
Mailing Address - Phone:936-560-2990
Mailing Address - Fax:
Practice Address - Street 1:1300 N MOUND ST
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-4029
Practice Address - Country:US
Practice Address - Phone:936-560-2990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE2718207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX81K363OtherBLUE CROSS BLUE SHIELD
TX00F82YMedicare ID - Type Unspecified
TXC19193Medicare UPIN