MEDICARE: MR. ROGER FAIR CLEM CCC-A

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	231H00000X	Audiologist	3510	GA

General Provider Information

NPI Number	:	1457481491
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROGER FAIR CLEM CCC-A

Provider Business Mailing Address
First Line	:	1606 LAKE MARINA DR
Second Line	:
City	:	HIXSON
State	:	TN
Zip	:	37343-4661
Country	:	US
Telephone Number	:	423-877-5570
Fax Number	:

Provider Business Practice Location Address
First Line	:	140 BATTLEWOOD DR
Second Line	:
City	:	FORT OGLETHORPE
State	:	GA
Zip	:	30742-4006
Country	:	US
Telephone Number	:	706-861-7070
Fax Number	:

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

Provider Enumeration Date	:	03/07/2007
Last Update Date	:	07/09/2007

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