Provider Demographics
NPI:1922288224
Name:TOREY B. CLARK, MD PC
Entity Type:Organization
Organization Name:TOREY B. CLARK, MD PC
Other - Org Name:MEDICAL ONCOLOGY & PALLIATIVE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:TOREY
Authorized Official - Middle Name:B
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-817-5355
Mailing Address - Street 1:500 W LANIER AVE
Mailing Address - Street 2:SUITE 406
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-7636
Mailing Address - Country:US
Mailing Address - Phone:678-817-5355
Mailing Address - Fax:678-817-5339
Practice Address - Street 1:500 W LANIER AVE
Practice Address - Street 2:SUITE 406
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-7636
Practice Address - Country:US
Practice Address - Phone:678-817-5355
Practice Address - Fax:678-817-5339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036943174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP4553Medicare PIN