Provider Demographics
NPI:1306845573
Name:CLARK FAMILY MEDICINE PA
Entity Type:Organization
Organization Name:CLARK FAMILY MEDICINE PA
Other - Org Name:CLARK FAMILY & OBSTETRIC CARE PA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:828-528-3009
Mailing Address - Street 1:PO BOX 58
Mailing Address - Street 2:
Mailing Address - City:CROSSNORE
Mailing Address - State:NC
Mailing Address - Zip Code:28616-0058
Mailing Address - Country:US
Mailing Address - Phone:828-528-3009
Mailing Address - Fax:
Practice Address - Street 1:137 NOTALEE ST
Practice Address - Street 2:
Practice Address - City:NEWLAND
Practice Address - State:NC
Practice Address - Zip Code:28657
Practice Address - Country:US
Practice Address - Phone:828-528-3009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0098-01210207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89013VRMedicaid
NC2326922Medicare ID - Type Unspecified