Provider Demographics
NPI:1215085790
Name:MCLEAN, CONWAY T (DPM)
Entity type:Individual
Prefix:
First Name:CONWAY
Middle Name:T
Last Name:MCLEAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 W WASHINGTON ST STE B
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-4164
Mailing Address - Country:US
Mailing Address - Phone:906-225-7707
Mailing Address - Fax:
Practice Address - Street 1:700 W WASHINGTON ST STE B
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-4164
Practice Address - Country:US
Practice Address - Phone:906-225-7707
Practice Address - Fax:906-225-7710
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002555213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY006601OtherPODIATRY LICENSE