Provider Demographics
NPI:1578511010
Name:MERIDIAN MEDICAL GROUP-RETAIL CLINIC PC
Entity Type:Organization
Organization Name:MERIDIAN MEDICAL GROUP-RETAIL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-765-6317
Mailing Address - Street 1:PO BOX 19597
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4090
Mailing Address - Country:US
Mailing Address - Phone:713-580-9491
Mailing Address - Fax:713-358-4868
Practice Address - Street 1:3600 ROUTE 66 FL 3
Practice Address - Street 2:
Practice Address - City:NEPTUNE
Practice Address - State:NJ
Practice Address - Zip Code:07753-2605
Practice Address - Country:US
Practice Address - Phone:732-807-0800
Practice Address - Fax:732-922-0805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ096839Medicare PIN