Provider Demographics
NPI:1659355121
Name:CLARK, RICHARD D (RN ARNP CRNA)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:D
Last Name:CLARK
Suffix:
Gender:M
Credentials:RN ARNP CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18221 TORRENCE AVE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:IL
Mailing Address - Zip Code:60438-2870
Mailing Address - Country:US
Mailing Address - Phone:708-895-9408
Mailing Address - Fax:
Practice Address - Street 1:18221 TORRENCE AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:IL
Practice Address - Zip Code:60438-2870
Practice Address - Country:US
Practice Address - Phone:708-895-9450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2010-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1484659051163W00000X
MO134677163W00000X, 367500000X
KS54725363L00000X, 367500000X
IL09.006191367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
161280OtherBCBS OF KANSAS
481192875OtherHUMANA
P00155221OtherRR MEDICARE
P13178OtherPREMIER HEALTH PLANS
27862039OtherBCBS OF KANSAS CITY
27862039OtherPREFERRED HEALTH PROFESSI
27862039OtherPREFERRED CARE BLUE
481192875OtherUNITED HEALTH CARE
481192875OtherCOVENTRY
MO915697213Medicaid
481192875OtherCIGNA
481192875OtherAETNA
100385650COtherKANSAS MEDICAL ASSISTISTA
10001771600OtherCOMMUNITY HEALTH PLAN
10001771600OtherCOMMUNITY HEALTH PLAN
27862039OtherPREFERRED HEALTH PROFESSI
KS161280Medicare ID - Type Unspecified
481192875OtherCOVENTRY