Provider Demographics
NPI:1023314549
Name:MCCLELLAN, STEPHEN LEE (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:LEE
Last Name:MCCLELLAN
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:PO BOX 191
Mailing Address - Street 2:
Mailing Address - City:KEWAUNEE
Mailing Address - State:WI
Mailing Address - Zip Code:54216-0191
Mailing Address - Country:US
Mailing Address - Phone:920-388-0569
Mailing Address - Fax:920-388-2760
Practice Address - Street 1:N4656 LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:KEWAUNEE
Practice Address - State:WI
Practice Address - Zip Code:54216-9794
Practice Address - Country:US
Practice Address - Phone:920-388-0569
Practice Address - Fax:920-388-2760
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-31
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI22454-20207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL043981900Medicaid
FL043981900Medicaid
01429ZMedicare PIN