Provider Demographics
NPI:1982680641
Name:ST. CLEMENTS MEDICAL CARE, LLC
Entity Type:Organization
Organization Name:ST. CLEMENTS MEDICAL CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:MCCALL
Authorized Official - Last Name:WILKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-997-0611
Mailing Address - Street 1:23130 MOAKLEY ST
Mailing Address - Street 2:
Mailing Address - City:LEONARDTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20650-2918
Mailing Address - Country:US
Mailing Address - Phone:301-997-0611
Mailing Address - Fax:301-997-0709
Practice Address - Street 1:23130 MOAKLEY ST
Practice Address - Street 2:
Practice Address - City:LEONARDTOWN
Practice Address - State:MD
Practice Address - Zip Code:20650-2918
Practice Address - Country:US
Practice Address - Phone:301-997-0611
Practice Address - Fax:301-997-0709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-15
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0055682207Q00000X
MDD0047849207Q00000X
MDD0059422207Q00000X
MDPA59937363AM0700X
MDPA66598363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD511108100Medicaid
MD511108100Medicaid
MDG08346Medicare UPIN
MDH02743Medicare UPIN
MD402MMedicare PIN