1417942657 NPI number — MARK S CLEM PA-C

Table of content: MARK S CLEM PA-C (NPI 1417942657)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417942657 NPI number — MARK S CLEM PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLEM
Provider First Name:
MARK
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417942657
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/04/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
304 WRIGHT ST
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
SWEETWATER
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37874-1181
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-632-5900
Provider Business Mailing Address Fax Number:
865-546-5227

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9125 CROSS PARK DR
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
KNOXVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37923-4505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-632-5900
Provider Business Practice Location Address Fax Number:
865-546-5227
Provider Enumeration Date:
09/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  110001634 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X , with the licence number: PA1617 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 010184487 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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