Healthcare Provider Details

I. General information

NPI: 1659571503
Provider Name (Legal Business Name): KRISTIN LYNN REMKE CLARY D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2007
Last Update Date: 10/13/2022
Certification Date: 10/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 MEDICAL PARK DEPT OF PSYCHIATRY
COLUMBIA SC
29203
US

IV. Provider business mailing address

14 MONCKTON BLVD STE 100A
COLUMBIA SC
29206-4723
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-4300
  • Fax: 803-434-4351
Mailing address:
  • Phone: 803-764-3555
  • Fax: 803-764-4418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberLL1079
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: