Provider Demographics
NPI:1336147289
Name:CLARK, MICHAEL (PT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1186
Mailing Address - Street 2:
Mailing Address - City:FAIRHOPE
Mailing Address - State:AL
Mailing Address - Zip Code:36533-1186
Mailing Address - Country:US
Mailing Address - Phone:251-928-2401
Mailing Address - Fax:251-928-5099
Practice Address - Street 1:341 GREENO ROAD
Practice Address - Street 2:
Practice Address - City:FAIRHOPE
Practice Address - State:AL
Practice Address - Zip Code:36532
Practice Address - Country:US
Practice Address - Phone:251-928-2401
Practice Address - Fax:251-928-5099
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH24652251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051077610OtherBCBS
AL890006680Medicaid