Provider Demographics
NPI:1356591523
Name:CLARK RADIOLOGY, PLLC
Entity type:Organization
Organization Name:CLARK RADIOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:HOMER
Authorized Official - Last Name:MCQUAIDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-226-3858
Mailing Address - Street 1:PO BOX 1820
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40602-1820
Mailing Address - Country:US
Mailing Address - Phone:502-226-3858
Mailing Address - Fax:502-223-9829
Practice Address - Street 1:1107 W LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40391-1169
Practice Address - Country:US
Practice Address - Phone:502-226-3858
Practice Address - Fax:502-223-9829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-24
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY288862085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty