Provider Demographics
NPI:1073506051
Name:MCKENZIE, CLARK R (MD)
Entity Type:Individual
Prefix:DR
First Name:CLARK
Middle Name:R
Last Name:MCKENZIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 N NEW BALLAS RD
Mailing Address - Street 2:STE 270 W
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-2632
Mailing Address - Country:US
Mailing Address - Phone:314-991-6969
Mailing Address - Fax:314-997-6969
Practice Address - Street 1:450 N NEW BALLAS RD
Practice Address - Street 2:STE 270 W
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63195-2632
Practice Address - Country:US
Practice Address - Phone:314-991-6969
Practice Address - Fax:314-997-6969
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4P62207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO004013185OtherMEDICARE PROV ID AREA 99
MO1124011010OtherHHC CATH GROUP NPI
MO1881863009OtherFARM GROUP NPI
MOP00275849OtherRR CCL GROUP
006012762OtherMEDICARE PROVIDER ID
MO110171721OtherRR MEDICARE NUMBER
MO000047049OtherMCARE CCL GROUP NUMBER
MOCI7050OtherRR GROUP 99
MOMA1080OtherCCL GROUP NUMBER
MO1801889795OtherSTL GROUP NPI
MOMA1080001OtherCCL INDIVDUAL PROV NUMBER
MOCD6536OtherRR GROUP 01
MOMA1080001OtherCCL INDIVDUAL PROV NUMBER