Provider Demographics
NPI:1902942022
Name:CLEMSON UNIVERSITY ATHLETIC DEPARTMENT
Entity Type:Organization
Organization Name:CLEMSON UNIVERSITY ATHLETIC DEPARTMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASST ATHLETIC DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-656-0128
Mailing Address - Street 1:PO BOX 31
Mailing Address - Street 2:
Mailing Address - City:CLEMSON
Mailing Address - State:SC
Mailing Address - Zip Code:29633-0031
Mailing Address - Country:US
Mailing Address - Phone:864-656-2113
Mailing Address - Fax:864-656-6408
Practice Address - Street 1:100 PERIMETER RD
Practice Address - Street 2:
Practice Address - City:CLEMSON
Practice Address - State:SC
Practice Address - Zip Code:29634-0001
Practice Address - Country:US
Practice Address - Phone:864-656-2113
Practice Address - Fax:864-656-6408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC=========011OtherBCBS PROVIDER ID