Provider Demographics
NPI:1427217090
Name:WILLIAM E. CLACK M.D.
Entity Type:Organization
Organization Name:WILLIAM E. CLACK M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:E
Authorized Official - Last Name:CLACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:607-733-3631
Mailing Address - Street 1:447 E WATER ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-3410
Mailing Address - Country:US
Mailing Address - Phone:607-733-3631
Mailing Address - Fax:607-733-5432
Practice Address - Street 1:447 E WATER ST
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14901-3410
Practice Address - Country:US
Practice Address - Phone:607-733-3631
Practice Address - Fax:607-733-5432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-08
Last Update Date:2008-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY118121174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00359366Medicaid
NY00359366Medicaid