Basic Information
| Provider Information | |||||||||
| NPI: | 1407806557 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLODFELTER | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4750 HEMPSTEAD STATION DR | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454295164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008750136 | ||||||||
| FaxNumber: | 9376194231 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 HOSPITAL MEDICAL CENTER | ||||||||
| Address2: | |||||||||
| City: | HILTON HEAD | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436898281 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 03/04/2009 | ||||||||
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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 | 207P00000X | 19445 | SC | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 194453 | 05 | SC | MEDICAID | P00114180 | 01 | RR MEDICARE | OTHER | 115145684A | 05 | GA | MEDICAID | 20028894 | 01 | SELECT HEALTH | OTHER |