Provider Demographics
NPI:1790970937
Name:PETER CLARK, MD, PC
Entity Type:Organization
Organization Name:PETER CLARK, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-898-3341
Mailing Address - Street 1:220 W SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:NY
Mailing Address - Zip Code:13073-1237
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:607-898-3982
Practice Address - Street 1:220 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:NY
Practice Address - Zip Code:13073-1237
Practice Address - Country:US
Practice Address - Phone:607-898-3341
Practice Address - Fax:607-898-3982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-11
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY181768207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01314507Medicaid
NY53435BMedicare PIN