Provider Demographics
NPI:1629015953
Name:CLARK MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:CLARK MEMORIAL HOSPITAL
Other - Org Name:PRIMARY CARE SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT FINANCE CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:STRACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-283-2488
Mailing Address - Street 1:1806 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130
Mailing Address - Country:US
Mailing Address - Phone:812-285-5926
Mailing Address - Fax:812-280-5723
Practice Address - Street 1:1806 E 10TH ST
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130
Practice Address - Country:US
Practice Address - Phone:812-285-5926
Practice Address - Fax:812-280-5723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CI1990OtherRAILROAD MEDICARE GROUP
CD6896OtherRAILROAD MEDICARE GROUP
IN100074370Medicaid
IN128940Medicare PIN