1104829688 NPI number — STANLEY D CLARKE M.D.

Table of content: STANLEY D CLARKE M.D. (NPI 1104829688)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104829688 NPI number — STANLEY D CLARKE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARKE
Provider First Name:
STANLEY
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104829688
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15055 COLLECTION CENTER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60693-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-383-3325
Provider Business Mailing Address Fax Number:
480-212-8451

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1110 S JACKSON HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHEFFIELD
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35660-5747
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-383-5211
Provider Business Practice Location Address Fax Number:
256-381-1517
Provider Enumeration Date:
05/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0001X , with the licence number:  00019049 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 051504899 . This is a "AL BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 051504900 . This is a "AL BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 529909740 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 103413 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 515-45255 . This is a "BCBS AL" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 515-45256 . This is a "BCBS AL" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 103086 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009973900 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 051550973 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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