Healthcare Provider Details

I. General information

NPI: 1154418150
Provider Name (Legal Business Name): WILSON MONROE CLEMENTS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 12/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2108 E 3RD ST SUITE 300
CHATTANOOGA TN
37404-2600
US

IV. Provider business mailing address

2501 CITICO AVE
CHATTANOOGA TN
37404-1127
US

V. Phone/Fax

Practice location:
  • Phone: 423-624-5200
  • Fax: 423-624-4440
Mailing address:
  • Phone: 423-697-2000
  • Fax: 423-697-2118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number2010-01100
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number42073
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number52593
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: