Basic Information
| Provider Information | |||||||||
| NPI: | 1154418150 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLEMENTS | ||||||||
| FirstName: | WILSON | ||||||||
| MiddleName: | MONROE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2501 CITICO AVE | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374041127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236972000 | ||||||||
| FaxNumber: | 4236972118 | ||||||||
| Practice Location | |||||||||
| Address1: | 2108 E 3RD ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374042600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236245200 | ||||||||
| FaxNumber: | 4236244440 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 12/02/2016 | ||||||||
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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 | 208G00000X | 2010-01100 | NC | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208G00000X | 42073 | KY | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208G00000X | 52593 | TN | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 7100070870 | 05 | KY | MEDICAID | 1589G | 01 | NC | BCBSNC | OTHER | 5915281 | 05 | NC | MEDICAID |