Basic Information
| Provider Information | |||||||||
| NPI: | 1730177262 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLEMMENS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12622 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049154017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434816482 | ||||||||
| FaxNumber: | 4434816515 | ||||||||
| Practice Location | |||||||||
| Address1: | 2001 MEDICAL PKWY | ||||||||
| Address2: | |||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214013280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434811000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2005 | ||||||||
| LastUpdateDate: | 12/08/2013 | ||||||||
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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 | 208000000X | D0041415 | MD | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 2559709 2573474 | 01 | MD | AETNA HMO | OTHER | 507000702 | 05 | MD | MEDICAID | 079171700 | 05 | MD | MEDICAID | 52427806 | 01 | MD | CAREFIRST AAPG | OTHER | Y1220005 | 01 | MD | CAREFIRST AAPG | OTHER |