Basic Information
| Provider Information | |||||||||
| NPI: | 1487073334 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLEMENS | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2335 HAWKINS AVE | ||||||||
| Address2: | |||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480734804 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3990 JOHN R ST | ||||||||
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| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137457233 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2014 | ||||||||
| LastUpdateDate: | 03/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 4301105921 | MI | N | Allopathic & Osteopathic Physicians | Anesthesiology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207LC0200X | 4301105921 | MI | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine |
No ID Information.