1326090911 NPI number — TERENCE JOSEPH CLARKE MD

Table of content: MYESHEA BURTON QBHP (NPI 1912595604)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326090911 NPI number — TERENCE JOSEPH CLARKE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARKE
Provider First Name:
TERENCE
Provider Middle Name:
JOSEPH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1326090911
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
893 GROOMS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
REXFORD
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12148-1305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-859-8271
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7 SOUTHWOODS BLVD STE 17
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBANY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12211-2564
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-641-6580
Provider Business Practice Location Address Fax Number:
518-292-6088
Provider Enumeration Date:
05/16/2006

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: 208600000X , with the licence number:  222853 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 11323390 . This is a "CAQH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 3715H1 . This is a "BLUE CROSS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 7370593 . This is a "AETNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000072573 . This is a "GHI-HMO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000415749001 . This is a "BLUE SHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 10088694 . This is a "CDPHP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 7515N2 . This is a "BLUE CROSS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 050127000002 . This is a "FIDELIS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 5996001 . This is a "GHIPPO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 782956 . This is a "MVP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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