Basic Information
| Provider Information | |||||||||
| NPI: | 1194714311 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCLAIN | ||||||||
| FirstName: | JOCELYN | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCCLAIN HAZELWOOD | ||||||||
| OtherFirstName: | JOCELYN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8600 N STATE ROUTE 91 | ||||||||
| Address2: | STE 250 | ||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616159508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096925393 | ||||||||
| FaxNumber: | 3096922538 | ||||||||
| Practice Location | |||||||||
| Address1: | 8600 N STATE ROUTE 91 | ||||||||
| Address2: | STE 250 | ||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616159508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096925393 | ||||||||
| FaxNumber: | 3096922538 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2005 | ||||||||
| LastUpdateDate: | 08/04/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 036084708 | IL | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 036084708 | IL | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207Q00000X | 036084708 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036084708 | 05 | IL | MEDICAID |