Provider Demographics
NPI:1326079039
Name:ROBERT B CLARK JR MD LLC
Entity Type:Organization
Organization Name:ROBERT B CLARK JR MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:PRISCILLA
Authorized Official - Middle Name:E
Authorized Official - Last Name:EDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-537-8691
Mailing Address - Street 1:1811 MANNING DRIVE
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474
Mailing Address - Country:US
Mailing Address - Phone:912-537-6634
Mailing Address - Fax:912-537-1909
Practice Address - Street 1:1811 MANNING DRIVE
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474
Practice Address - Country:US
Practice Address - Phone:912-537-6634
Practice Address - Fax:912-537-1909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA020521174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA449866340OtherMEDICAID REFERRAL
GA000177713DMedicaid
GU1144289349OtherPERSONAL NPI NUMBER 1144289349
GAGRP7739OtherMEDICARE GROUP NUMBER