Provider Demographics
NPI:1942513353
Name:MCLEAN, KIMBERLY GRILLO (DO)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:GRILLO
Last Name:MCLEAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:LYNN
Other - Last Name:GRILLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:4125 BINGHAMPTON CT
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48348-5078
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:50 N PERRY ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48342-2217
Practice Address - Country:US
Practice Address - Phone:248-338-5392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-15
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI01923207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery