Provider Demographics
NPI:1487664835
Name:CLARKE, KEVIN M (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:CLARKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 RT 98 WEST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:NUTTER FORT
Mailing Address - State:WV
Mailing Address - Zip Code:26301
Mailing Address - Country:US
Mailing Address - Phone:304-623-5711
Mailing Address - Fax:304-624-0461
Practice Address - Street 1:48 VIP WAY
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554
Practice Address - Country:US
Practice Address - Phone:304-366-6200
Practice Address - Fax:304-366-4927
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV15547207R00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001722242OtherBCBS WV
WV0041752000Medicaid
9293261Medicare ID - Type Unspecified
WV0041752000Medicaid