Basic Information
| Provider Information | |||||||||
| NPI: | 1164420576 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLEMENT | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1076 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029045760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4018617711 | ||||||||
| FaxNumber: | 4014215710 | ||||||||
| Practice Location | |||||||||
| Address1: | 1076 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029045760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4018617711 | ||||||||
| FaxNumber: | 4014215710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2005 | ||||||||
| LastUpdateDate: | 12/04/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | RI09696 | RI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RN0300X | RI09696 | RI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 7006284 | 05 | RI | MEDICAID |