Provider Demographics
NPI:1700188901
Name:JOHN ROBERT CLARK MD PC
Entity Type:Organization
Organization Name:JOHN ROBERT CLARK MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-659-4646
Mailing Address - Street 1:600 S LAKEVIEW AVE STE 207
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:MI
Mailing Address - Zip Code:49091-2372
Mailing Address - Country:US
Mailing Address - Phone:269-659-4646
Mailing Address - Fax:269-651-2210
Practice Address - Street 1:600 S LAKEVIEW AVE STE 207
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:MI
Practice Address - Zip Code:49091-2372
Practice Address - Country:US
Practice Address - Phone:269-659-4646
Practice Address - Fax:269-651-2210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-22
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301062758207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3044976Medicaid
C78427Medicare UPIN
MI3044976Medicaid