Provider Demographics
NPI:1831344431
Name:CLARK PHYSICIAN GROUP LLC
Entity type:Organization
Organization Name:CLARK PHYSICIAN GROUP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:
Authorized Official - Last Name:STRACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-282-6631
Mailing Address - Street 1:130 HUNTER STATION WAY
Mailing Address - Street 2:
Mailing Address - City:SELLERSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47172-8930
Mailing Address - Country:US
Mailing Address - Phone:812-246-4808
Mailing Address - Fax:812-246-4807
Practice Address - Street 1:130 HUNTER STATION WAY
Practice Address - Street 2:
Practice Address - City:SELLERSBURG
Practice Address - State:IN
Practice Address - Zip Code:47172-8930
Practice Address - Country:US
Practice Address - Phone:812-246-4808
Practice Address - Fax:812-246-4807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-24
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200843050Medicaid
IN258910Medicare PIN
IN6186000001Medicare NSC