MEDICARE: M L CLEMSON CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WP0809X	Adult Psychiatric/Mental Health Registered Nurse	0015000529	VA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	C08982	OTHER	VA	MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	101867	OTHER	VA	ANTHEM GROUP
3	101868	OTHER	VA	ANTHEM
4	P00071810	OTHER	VA	RAILROAD
5	1750563086	OTHER	VA	INDIVIDUAL NPI

General Provider Information

NPI Number	:	1033127188
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	M L CLEMSON CORPORATION

Provider Business Mailing Address
First Line	:	602 MASSACHUSETTS AVE
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23508-2118
Country	:	US
Telephone Number	:	757-622-6673
Fax Number	:	757-622-1086

Provider Business Practice Location Address
First Line	:	602 MASSACHUSETTS AVE
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23508-2118
Country	:	US
Telephone Number	:	757-622-6673
Fax Number	:	757-622-1086

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. MARY LOUISE CLEMSON
Credential	:	PSY CNS
Telephone Number	:	757-622-6673

Provider Enumeration Date	:	08/04/2006
Last Update Date	:	03/26/2008

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Directions to “M L CLEMSON CORPORATION ” Practice Location

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