Provider Demographics
NPI:1740510759
Name:CLARK-ALBERT, GEORGIA (MS RD LD CDE)
Entity type:Individual
Prefix:
First Name:GEORGIA
Middle Name:
Last Name:CLARK-ALBERT
Suffix:
Gender:F
Credentials:MS RD LD CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 934
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-0934
Mailing Address - Country:US
Mailing Address - Phone:207-907-1187
Mailing Address - Fax:207-907-1189
Practice Address - Street 1:900 BROADWAY
Practice Address - Street 2:BLDG 1
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-1900
Practice Address - Country:US
Practice Address - Phone:207-907-1187
Practice Address - Fax:207-907-1189
Is Sole Proprietor?:No
Enumeration Date:2010-01-14
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDI426133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME710000822OtherRAILROAD MEDICARE PROGRAM
MECL MT0437Medicare PIN