Basic Information
Provider Information | |||||||||
NPI: | 1588907810 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCCLELLAND | ||||||||
FirstName: | ISLA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 180 HARVESTER DR STE 110 | ||||||||
Address2: |   | ||||||||
City: | BURR RIDGE | ||||||||
State: | IL | ||||||||
PostalCode: | 605276686 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7737021150 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 473 W 12TH AVE STE 200 | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | OH | ||||||||
PostalCode: | 432101252 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6142938761 | ||||||||
FaxNumber: | 6142935614 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/04/2013 | ||||||||
LastUpdateDate: | 06/08/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/08/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0101258986 | VA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RC0000X | 036142585 | IL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RA0002X | 57.248772 | OH | Y |   |   |   |   |
No ID Information.