Provider Demographics
NPI:1174588651
Name:MCCLELLAN, CHRISTOPHER S (MD)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:S
Last Name:MCCLELLAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2425 LIME KILN LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-3462
Mailing Address - Country:US
Mailing Address - Phone:502-899-7163
Mailing Address - Fax:502-897-9963
Practice Address - Street 1:112 SEARS AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-5014
Practice Address - Country:US
Practice Address - Phone:502-238-2163
Practice Address - Fax:502-238-2173
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY34957207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000225513OtherANTHEM / NCMA
KY110235213OtherRAILROAD MEDICARE
KY012817OtherSIHO / NCMA
KY000026447NOtherHUMANA / NCMA
KY2439608000OtherPASSPORT ADVANTAGE / NCMA
KY64046287Medicaid
IN200381960Medicaid
KY0361931Medicare PIN
KY000026447NOtherHUMANA / NCMA