Provider Demographics
NPI:1699766436
Name:CLEMSON NEUROLOGY
Entity type:Organization
Organization Name:CLEMSON NEUROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:S
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-653-4071
Mailing Address - Street 1:220 KEOWEE TRL
Mailing Address - Street 2:
Mailing Address - City:CLEMSON
Mailing Address - State:SC
Mailing Address - Zip Code:29631-1448
Mailing Address - Country:US
Mailing Address - Phone:864-653-4071
Mailing Address - Fax:864-653-4074
Practice Address - Street 1:220 KEOWEE TRL
Practice Address - Street 2:
Practice Address - City:CLEMSON
Practice Address - State:SC
Practice Address - Zip Code:29631-1448
Practice Address - Country:US
Practice Address - Phone:864-653-4071
Practice Address - Fax:864-653-4074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-01
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3805Medicaid
SC=========OtherUNITED HEALTHCARE
SCGP3805Medicaid
SC=========OtherTRICARE
SC=========OtherBLUE CHOICE
SC=========OtherSTANDARD TAX ID
SC=========OtherTRICARE
SC=========OtherBLUE CHOICE