Provider Demographics
NPI:1992772446
Name:MCCLAIN, BOELDRIDGE (MD)
Entity type:Individual
Prefix:DR
First Name:BOELDRIDGE
Middle Name:
Last Name:MCCLAIN
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 1:1266 E CAROLINE LN
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-3363
Mailing Address - Country:US
Mailing Address - Phone:623-512-3893
Mailing Address - Fax:
Practice Address - Street 1:1266 E CAROLINE LN
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85284-3363
Practice Address - Country:US
Practice Address - Phone:623-512-3893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-03
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI14954207L00000X
AZ30909207LP2900X, 208VP0000X, 207L00000X
GA061624207L00000X
WI44175207L00000X
MI4301093420207L00000X
FLME102957207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ920703Medicaid
H79509Medicare UPIN
AZ920703Medicaid