Provider Demographics
NPI:1518030873
Name:CLEMENTS, PHILIP CARLISLE (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:CARLISLE
Last Name:CLEMENTS
Suffix:
Gender:M
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:PO BOX 14890
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212-4890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:585 NEW LONDON RD
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-5701
Practice Address - Country:US
Practice Address - Phone:518-783-1472
Practice Address - Fax:518-783-1605
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171241207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01698282Medicaid
E51422Medicare UPIN
NY01698282Medicaid