1275596041 NPI number — DR. MICHAEL T CLARK D. C.

Table of content: DR. MICHAEL T CLARK D. C. (NPI 1275596041)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275596041 NPI number — DR. MICHAEL T CLARK D. C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
MICHAEL
Provider Middle Name:
T
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D. C.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CLARK
Provider Other First Name:
MICHAEL
Provider Other Middle Name:
T
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.C.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1275596041
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23 CHARLES ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03867-2926
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-332-8989
Provider Business Mailing Address Fax Number:
603-332-8989

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23 CHARLES ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03867-2926
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-332-8989
Provider Business Practice Location Address Fax Number:
603-332-8989
Provider Enumeration Date:
04/11/2006

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: 111N00000X , with the licence number:  11809510184A , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 19394 . This is a "MATTHEW THORNTON HEALTH P" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 7802 OUT OF STATE . This is a "ANTHEM NJ" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 80705 . This is a "GREAT WEST HC" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: AA44982 . This is a "HPHC" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 63665 . This is a "GREAT WEST NA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0508438Y0NH01 . This is a "ANTHEM" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 453731 . This is a "AETNA" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 30001768 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3228 . This is a "CIGNA" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".




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