Provider Demographics
NPI:1578645768
Name:CLARK, MICHAEL PATRICK SR (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:PATRICK
Last Name:CLARK
Suffix:SR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:214 FALCONHURST DR N
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15238-2628
Mailing Address - Country:US
Mailing Address - Phone:412-826-8805
Mailing Address - Fax:412-486-1552
Practice Address - Street 1:633 MOUNT ROYAL BLVD
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15223-1225
Practice Address - Country:US
Practice Address - Phone:412-486-3355
Practice Address - Fax:412-486-3355
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PADC003464-L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA502508Medicare ID - Type Unspecified