Provider Demographics
NPI:1154418150
Name:CLEMENTS, WILSON MONROE (MD)
Entity type:Individual
Prefix:
First Name:WILSON
Middle Name:MONROE
Last Name:CLEMENTS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 CITICO AVE
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404-1127
Mailing Address - Country:US
Mailing Address - Phone:423-697-2000
Mailing Address - Fax:423-697-2118
Practice Address - Street 1:2108 E 3RD ST
Practice Address - Street 2:SUITE 300
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-2600
Practice Address - Country:US
Practice Address - Phone:423-624-5200
Practice Address - Fax:423-624-4440
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2010-01100208G00000X
KY42073208G00000X
TN52593208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100070870Medicaid
NC1589GOtherBCBSNC
NC5915281Medicaid
NC2076341Medicare PIN
NC1589GOtherBCBSNC