Provider Demographics
NPI: | 1487682373 |
---|---|
Name: | CLARK-HOLDER CLINIC, P.A. |
Entity Type: | Organization |
Organization Name: | CLARK-HOLDER CLINIC, P.A. |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CFO/CONTROLLER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | DONALD |
Authorized Official - Middle Name: | J |
Authorized Official - Last Name: | HARMON |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 706-812-4313 |
Mailing Address - Street 1: | CLARK-HOLDER CLINIC, P.A. |
Mailing Address - Street 2: | 303 SMITH STREET |
Mailing Address - City: | LAGRANGE |
Mailing Address - State: | GA |
Mailing Address - Zip Code: | 30240 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 706-882-8831 |
Mailing Address - Fax: | 706-812-4091 |
Practice Address - Street 1: | CLARK-HOLDER CLINIC, P.A. |
Practice Address - Street 2: | 303 SMITH STREET |
Practice Address - City: | LAGRANGE |
Practice Address - State: | GA |
Practice Address - Zip Code: | 30240 |
Practice Address - Country: | US |
Practice Address - Phone: | 706-882-8831 |
Practice Address - Fax: | 706-812-4091 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-06-29 |
Last Update Date: | 2020-08-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Not Answered | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
Not Answered | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
Not Answered | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
Not Answered | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | Group - Multi-Specialty |
Not Answered | 207RH0003X | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | Group - Multi-Specialty |
Not Answered | 207RI0200X | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | Group - Multi-Specialty |
Not Answered | 207RP1001X | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | Group - Multi-Specialty |
Not Answered | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
Not Answered | 207W00000X | Allopathic & Osteopathic Physicians | Ophthalmology | Group - Multi-Specialty | |
Not Answered | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
Not Answered | 207Y00000X | Allopathic & Osteopathic Physicians | Otolaryngology | Group - Multi-Specialty | |
Not Answered | 207YS0123X | Allopathic & Osteopathic Physicians | Otolaryngology | Facial Plastic Surgery | Group - Multi-Specialty |
Not Answered | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | Group - Multi-Specialty |
Not Answered | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
Not Answered | 208800000X | Allopathic & Osteopathic Physicians | Urology | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
GA | =========C | Medicare ID - Type Unspecified |