Provider Demographics
NPI:1154408151
Name:MICHAEL R. MCCLUNG MD
Entity type:Organization
Organization Name:MICHAEL R. MCCLUNG MD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:MS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:S
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-641-7173
Mailing Address - Street 1:417 SW 117TH AVE
Mailing Address - Street 2:STE. 120
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5924
Mailing Address - Country:US
Mailing Address - Phone:503-641-7173
Mailing Address - Fax:503-641-5254
Practice Address - Street 1:417 SW 117TH AVE
Practice Address - Street 2:STE. 120
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5924
Practice Address - Country:US
Practice Address - Phone:503-641-7173
Practice Address - Fax:503-641-5254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD10002261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0472267Medicaid
OR0472267Medicaid
C94436Medicare UPIN