Provider Demographics
NPI:1396944237
Name:CLARK, MICHAEL ROBERT (MD, MPH)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ROBERT
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 MINISTRY PKWY
Mailing Address - Street 2:
Mailing Address - City:SCHOFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54476-5220
Mailing Address - Country:US
Mailing Address - Phone:715-393-3723
Mailing Address - Fax:
Practice Address - Street 1:3400 MINISTRY PKWY
Practice Address - Street 2:
Practice Address - City:SCHOFIELD
Practice Address - State:WI
Practice Address - Zip Code:54476-5220
Practice Address - Country:US
Practice Address - Phone:715-393-3723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-11
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50630207P00000X, 207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100004191Medicaid
360450063OtherMEDICARE