Basic Information
| Provider Information | |||||||||
| NPI: | 1164540076 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLEMOW | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DUNCAN | ||||||||
| OtherFirstName: | DIANA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2000 E GREENVILLE ST | ||||||||
| Address2: | SUITE 3700 | ||||||||
| City: | ANDERSON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296211580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645121475 | ||||||||
| FaxNumber: | 8645121930 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 E GREENVILLE ST | ||||||||
| Address2: | SUITE 3700 | ||||||||
| City: | ANDERSON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296211580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645121475 | ||||||||
| FaxNumber: | 8645121930 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2007 | ||||||||
| LastUpdateDate: | 10/25/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 26919 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 269195 | 05 | SC | MEDICAID |