Provider Demographics
NPI:1386038214
Name:CLEM, ELISE REBECCA (MD)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:REBECCA
Last Name:CLEM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1041 BALCH RD STE 250
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-8822
Mailing Address - Country:US
Mailing Address - Phone:256-704-2229
Mailing Address - Fax:256-704-2235
Practice Address - Street 1:1041 BALCH RD STE 250
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-8822
Practice Address - Country:US
Practice Address - Phone:256-704-2229
Practice Address - Fax:256-704-2235
Is Sole Proprietor?:No
Enumeration Date:2015-03-28
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD35791207V00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL192546Medicaid