Basic Information
| Provider Information | |||||||||
| NPI: | 1710915780 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLEMONS | ||||||||
| FirstName: | ROBIN | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7147 SPRAGUE ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191191243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152476091 | ||||||||
| FaxNumber: | 8567947183 | ||||||||
| Practice Location | |||||||||
| Address1: | 70 COHANSEY ST | ||||||||
| Address2: | |||||||||
| City: | BRIDGETON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 083021918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8564514700 | ||||||||
| FaxNumber: | 8567947183 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MA04270100 | NJ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2486601 | 05 | NJ | MEDICAID |