Provider Demographics
NPI: | 1376095711 |
---|---|
Name: | NORTH CLARK MEDICAL GROUP LLC |
Entity Type: | Organization |
Organization Name: | NORTH CLARK MEDICAL GROUP LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CEO |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JOSEPH |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | NALLEY |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 502-244-9859 |
Mailing Address - Street 1: | 2100 MARKET ST STE 101 |
Mailing Address - Street 2: | |
Mailing Address - City: | CHARLESTOWN |
Mailing Address - State: | IN |
Mailing Address - Zip Code: | 47111-9535 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 812-503-5100 |
Mailing Address - Fax: | 770-573-9513 |
Practice Address - Street 1: | 1802 E 10TH ST |
Practice Address - Street 2: | |
Practice Address - City: | JEFFERSONVILLE |
Practice Address - State: | IN |
Practice Address - Zip Code: | 47130-6016 |
Practice Address - Country: | US |
Practice Address - Phone: | 812-288-2488 |
Practice Address - Fax: | 812-288-6603 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2016-11-02 |
Last Update Date: | 2024-03-21 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 208D00000X | Allopathic & Osteopathic Physicians | General Practice | Group - Multi-Specialty | |
No | 207RA0401X | Allopathic & Osteopathic Physicians | Internal Medicine | Addiction Medicine | Group - Multi-Specialty |
No | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | Group - Multi-Specialty |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 208VP0014X | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | Group - Multi-Specialty |
No | 251B00000X | Agencies | Case Management | Group - Multi-Specialty | |
No | 261QM0850X | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | Group - Multi-Specialty |
No | 261QM0855X | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | Group - Multi-Specialty |
No | 261QM1300X | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | Group - Multi-Specialty |
No | 261QM2800X | Ambulatory Health Care Facilities | Clinic/Center | Methadone | Group - Multi-Specialty |
No | 261QP2300X | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | Group - Multi-Specialty |
No | 261QU0200X | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | Group - Multi-Specialty |
No | 291U00000X | Laboratories | Clinical Medical Laboratory | ||
No | 324500000X | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Group - Multi-Specialty | |
No | 367500000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IN | 300010664 | Medicaid | |
KY | 7100535740 | Medicaid | |
IN | IN3604 | Other | MEDICARE IN |
KY | K258180 | Other | MEDICARE KY |