Provider Demographics
NPI:1922339373
Name:JILL E CLARK MD PC
Entity Type:Organization
Organization Name:JILL E CLARK MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:E
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-263-1621
Mailing Address - Street 1:1220 E 3900 S
Mailing Address - Street 2:STE 4I
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1377
Mailing Address - Country:US
Mailing Address - Phone:801-263-1621
Mailing Address - Fax:801-263-1647
Practice Address - Street 1:1220 E 3900 S
Practice Address - Street 2:STE 4I
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1377
Practice Address - Country:US
Practice Address - Phone:801-263-1621
Practice Address - Fax:801-263-1647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-26
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT73799221205208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT10281976OtherOWNERS DOB