Provider Demographics
NPI:1164401410
Name:CLARK, ROBERT JAMIE (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:JAMIE
Last Name:CLARK
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 1:2006 FRANKLIN ST. STE 301
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-4537
Mailing Address - Country:US
Mailing Address - Phone:256-539-9471
Mailing Address - Fax:256-539-9472
Practice Address - Street 1:101 SIVLEY RD
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-4421
Practice Address - Country:US
Practice Address - Phone:256-539-9471
Practice Address - Fax:256-539-9472
Is Sole Proprietor?:No
Enumeration Date:2006-01-14
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00018534207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009976005Medicaid
TN4044991OtherBCBS TN
AL51024084OtherHH LOCATIONS
AL000024084Medicaid
AL000024084Medicaid
GA050044087Medicare PIN
AL51024084OtherHH LOCATIONS