MEDICARE: DR. MACK H CLEMENTS MD

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	208D00000X	General Practice Physician	11304	GA
2	207Q00000X	Family Medicine Physician	11304	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255331351
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MACK H CLEMENTS MD

Provider Business Mailing Address
First Line	:	PO BOX 516
Second Line	:
City	:	PINE MOUNTAIN
State	:	GA
Zip	:	31822-0516
Country	:	US
Telephone Number	:	706-663-2574
Fax Number	:	706-663-5954

Provider Business Practice Location Address
First Line	:	211 EAST BROAD ST
Second Line	:
City	:	PINE MOUNTAIN
State	:	GA
Zip	:	31822-0516
Country	:	US
Telephone Number	:	706-663-2574
Fax Number	:	706-663-5954

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/29/2005
Last Update Date	:	10/14/2019

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