Provider Demographics
NPI:1306086848
Name:ST. CLEMENTS INTERNAL MEDICINE
Entity type:Organization
Organization Name:ST. CLEMENTS INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-997-0611
Mailing Address - Street 1:40900 MERCHANTS LN
Mailing Address - Street 2:SUITE 207
Mailing Address - City:LEONARDTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20650-3700
Mailing Address - Country:US
Mailing Address - Phone:301-997-1580
Mailing Address - Fax:301-997-0709
Practice Address - Street 1:23130 MOAKLEY ST
Practice Address - Street 2:
Practice Address - City:LEONARDTOWN
Practice Address - State:MD
Practice Address - Zip Code:20650-2918
Practice Address - Country:US
Practice Address - Phone:301-997-1313
Practice Address - Fax:301-997-0709
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. CLEMENTS MEDICAL CARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-24
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR063357363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD143000900Medicaid