Basic Information
| Provider Information | |||||||||
| NPI: | 1548528573 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARMODY | ||||||||
| FirstName: | CLAYTON | ||||||||
| MiddleName: | ALAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7640 SYLVANIA AVE STE B | ||||||||
| Address2: | |||||||||
| City: | SYLVANIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435609263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195178178 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7640 SYLVANIA AVE STE B | ||||||||
| Address2: | |||||||||
| City: | SYLVANIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195178178 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2012 | ||||||||
| LastUpdateDate: | 11/06/2019 | ||||||||
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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 | 207XX0005X | 35134940 | OH | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207XX0004X | MD60763576 | WA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | H648601 | 01 | OH | MEDICARE | OTHER | H648600 | 01 | OH | MEDICARE | OTHER | 0313996 | 05 | OH | MEDICAID |