Provider Demographics
NPI:1457579831
Name:CLARK, TIMOTHY M (CRNA)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:M
Last Name:CLARK
Suffix:
Gender:M
Credentials:CRNA
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 235022
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36123-5022
Mailing Address - Country:US
Mailing Address - Phone:334-386-2051
Mailing Address - Fax:334-396-6929
Practice Address - Street 1:800 MONTCLAIR RD
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35213-1908
Practice Address - Country:US
Practice Address - Phone:205-592-1785
Practice Address - Fax:205-783-3195
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-083920367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1267992Medicare PIN
ALQ66523Medicare UPIN