Provider Demographics
NPI:1164905535
Name:CLARK MEDICAL, PLLC
Entity Type:Organization
Organization Name:CLARK MEDICAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:405-693-5612
Mailing Address - Street 1:2601 N 3RD ST STE 106
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1144
Mailing Address - Country:US
Mailing Address - Phone:405-693-5612
Mailing Address - Fax:
Practice Address - Street 1:2601 N 3RD ST STE 106
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1144
Practice Address - Country:US
Practice Address - Phone:405-693-5612
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty