Basic Information
| Provider Information | |||||||||
| NPI: | 1992731681 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MACLENNAN | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24701 EUCLID AVE | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | EUCLID | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441171714 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11100 EUCLID AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441061716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168447494 | ||||||||
| FaxNumber: | 2162866341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2006 | ||||||||
| LastUpdateDate: | 08/25/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZB0001X | 35068763 | OH | N | Allopathic & Osteopathic Physicians | Pathology | Blood Banking & Transfusion Medicine | 207ZC0006X | 35068763 | OH | N | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology | 207ZC0500X | 35068763 | OH | N | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZD0900X | 35068763 | OH | N | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology | 207ZF0201X | 35068763 | OH | N | Allopathic & Osteopathic Physicians | Pathology | Forensic Pathology | 207ZH0000X | 35068763 | OH | N | Allopathic & Osteopathic Physicians | Pathology | Hematology | 207ZI0100X | 35068763 | OH | N | Allopathic & Osteopathic Physicians | Pathology | Immunopathology | 207ZM0300X | 35068763 | OH | N | Allopathic & Osteopathic Physicians | Pathology | Medical Microbiology | 207ZN0500X | 35068763 | OH | N | Allopathic & Osteopathic Physicians | Pathology | Neuropathology | 207ZP0007X | 35068763 | OH | N | Allopathic & Osteopathic Physicians | Pathology | Molecular Genetic Pathology | 207ZP0101X | 35068763 | OH | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology | 207ZP0102X | 35068763 | OH | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0104X | 35068763 | OH | N | Allopathic & Osteopathic Physicians | Pathology | Chemical Pathology | 207ZP0105X | 35068763 | OH | N | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine | 207ZP0213X | 35068763 | OH | N | Allopathic & Osteopathic Physicians | Pathology | Pediatric Pathology |
ID Information
| ID | Type | State | Issuer | Description | 000000224302 | 01 | OH | UNISON | OTHER | 0154381 | 05 | OH | MEDICAID | 000000528772 | 01 | OH | ANTHEM | OTHER | P00412500 | 01 | OH | RAILROAD MEDICARE | OTHER | 000000582772 | 01 | OH | ANTHEM | OTHER | 1100396 | 01 | OH | UHC | OTHER | 000000031604 | 01 | OH | ANTHEM | OTHER | 363794 | 01 | OH | WELLCARE | OTHER | 0127464 | 01 | OH | BCMH | OTHER | 220017463 | 01 | OH | RAILROAD MEDICARE | OTHER | 658175 | 01 | OH | AETNA | OTHER | 744995 | 01 | OH | BUCKEYE | OTHER |