Provider Demographics
NPI:1821154667
Name:ROBERT T CLARK MD PC
Entity Type:Organization
Organization Name:ROBERT T CLARK MD PC
Other - Org Name:CLARK TAIT EYE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-844-7744
Mailing Address - Street 1:7575 WEST GRAND RIVER
Mailing Address - Street 2:SUITE 111
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48114-9390
Mailing Address - Country:US
Mailing Address - Phone:810-844-7744
Mailing Address - Fax:810-844-7725
Practice Address - Street 1:7575 GRAND RIVER RD
Practice Address - Street 2:SUITE 111
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114-9309
Practice Address - Country:US
Practice Address - Phone:810-844-7744
Practice Address - Fax:810-844-7725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301040778207W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0297200001OtherDME SUPPLIER
MI102681557Medicaid
MI0D710210OtherGRP # BCBS
MI0D710210OtherGRP # BCBS