Provider Demographics
NPI:1801083134
Name:CLEMENTS PROFESSIONAL ASSOCIATION PINE MOUNTAIN
Entity type:Organization
Organization Name:CLEMENTS PROFESSIONAL ASSOCIATION PINE MOUNTAIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP SEC TRES AND MD
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:D
Authorized Official - Last Name:CLEMENTS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-663-2574
Mailing Address - Street 1:PO BOX 516
Mailing Address - Street 2:
Mailing Address - City:PINE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:31822-0516
Mailing Address - Country:US
Mailing Address - Phone:706-663-2574
Mailing Address - Fax:706-663-5954
Practice Address - Street 1:211 EAST BROAD ST
Practice Address - Street 2:
Practice Address - City:PINE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:31822-0516
Practice Address - Country:US
Practice Address - Phone:706-663-2574
Practice Address - Fax:706-663-5954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-01
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP1061Medicare PIN