Provider Demographics
NPI:1295702645
Name:KERR, CLARK
Entity type:Individual
Prefix:
First Name:CLARK
Middle Name:
Last Name:KERR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13200 PROVIDENCE LN
Mailing Address - Street 2:
Mailing Address - City:NORTH HUNTINGDON
Mailing Address - State:PA
Mailing Address - Zip Code:15642-2874
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12279 ROUTE 30
Practice Address - Street 2:
Practice Address - City:NORTH HUNTINGDON
Practice Address - State:PA
Practice Address - Zip Code:15642-1876
Practice Address - Country:US
Practice Address - Phone:724-864-7101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD024104E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA052381KDCOtherBLUE CROSS BLUE SHIELD
PA0857446Medicaid
PA052381KDCOtherBLUE CROSS BLUE SHIELD
PA052381KDCMedicare PIN