Provider Demographics
NPI:1164479762
Name:A. KENT CLARK
Entity Type:Organization
Organization Name:A. KENT CLARK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ARTHUR
Authorized Official - Middle Name:KENT
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-685-4777
Mailing Address - Street 1:841 UNION ST
Mailing Address - Street 2:STE A
Mailing Address - City:SHELBYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37160-2610
Mailing Address - Country:US
Mailing Address - Phone:931-685-4777
Mailing Address - Fax:931-685-4090
Practice Address - Street 1:841 UNION ST
Practice Address - Street 2:STE A
Practice Address - City:SHELBYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37160-2610
Practice Address - Country:US
Practice Address - Phone:931-685-4777
Practice Address - Fax:931-685-4090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN27339207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNG27053Medicare UPIN
TN3733381Medicare ID - Type Unspecified