Provider Demographics
NPI:1487290623
Name:MICHAEL P. CLEMENTS MD
Entity type:Organization
Organization Name:MICHAEL P. CLEMENTS MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:CLEMENTS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:575-973-5864
Mailing Address - Street 1:1096 MECHEM DR STE G05
Mailing Address - Street 2:
Mailing Address - City:RUIDOSO
Mailing Address - State:NM
Mailing Address - Zip Code:88345-7057
Mailing Address - Country:US
Mailing Address - Phone:575-973-5864
Mailing Address - Fax:575-258-2648
Practice Address - Street 1:1096 MECHEM DR STE G05
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345-7057
Practice Address - Country:US
Practice Address - Phone:575-973-5864
Practice Address - Fax:575-258-2648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-22
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing FacilityGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMQ0066Medicaid
NM67601081Medicaid