Provider Demographics
NPI:1457481491
Name:CLEM, ROGER FAIR (CCC-A)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:FAIR
Last Name:CLEM
Suffix:
Gender:M
Credentials:CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1606 LAKE MARINA DR
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-4661
Mailing Address - Country:US
Mailing Address - Phone:423-877-5570
Mailing Address - Fax:
Practice Address - Street 1:140 BATTLEWOOD DR
Practice Address - Street 2:
Practice Address - City:FORT OGLETHORPE
Practice Address - State:GA
Practice Address - Zip Code:30742-4006
Practice Address - Country:US
Practice Address - Phone:706-861-7070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3510231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA64BBBTZMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER