Basic Information
| Provider Information | |||||||||
| NPI: | 1518973577 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLEM | ||||||||
| FirstName: | KELLEY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4605 SAWMILL RD | ||||||||
| Address2: | |||||||||
| City: | UPPER ARLINGTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432202246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6148278700 | ||||||||
| FaxNumber: | 6148278701 | ||||||||
| Practice Location | |||||||||
| Address1: | 4605 SAWMILL RD | ||||||||
| Address2: | |||||||||
| City: | UPPER ARLINGTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432202246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6148278700 | ||||||||
| FaxNumber: | 6148278701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 01/21/2015 | ||||||||
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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 | 207QS0010X | 35-084799 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2691332 | 05 | OH | MEDICAID |