Provider Demographics
NPI:1124052972
Name:CLEMONS, STEVEN L
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:L
Last Name:CLEMONS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPT. 888152
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37995
Mailing Address - Country:US
Mailing Address - Phone:931-526-8513
Mailing Address - Fax:931-526-5422
Practice Address - Street 1:682 CANTER LN
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-4523
Practice Address - Country:US
Practice Address - Phone:931-526-8513
Practice Address - Fax:931-526-5422
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN37325174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3882671Medicaid
203554085OtherFEDERAL TAX ID
TN3732052Medicaid
TN4114638OtherBLUE CROSS BLUE SHIELD
TN3732052Medicaid
TN3882671Medicaid
203554085OtherFEDERAL TAX ID
TN3882671Medicaid