Provider Demographics
NPI:1992944193
Name:MARY KLEMENS MD PLLC
Entity type:Organization
Organization Name:MARY KLEMENS MD PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:CLIFTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-935-3549
Mailing Address - Street 1:800 COTTAGE VIEW DR
Mailing Address - Street 2:SUITE 1080B
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2490
Mailing Address - Country:US
Mailing Address - Phone:231-935-3549
Mailing Address - Fax:231-935-3548
Practice Address - Street 1:800 COTTAGE VIEW DR
Practice Address - Street 2:SUITE 1080B
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2490
Practice Address - Country:US
Practice Address - Phone:231-935-3549
Practice Address - Fax:231-935-3548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-11
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI431065488207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4369582Medicaid
MIG72307Medicare UPIN
MI4369582Medicaid