1386648087 NPI number — ROBERT THOMAS CLARK M.D.

Table of content: SYLVIE BERTRAND MD (NPI 1063115087)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386648087 NPI number — ROBERT THOMAS CLARK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
ROBERT
Provider Middle Name:
THOMAS
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:
1386648087
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/15/2006
NPI Reactivation Date:
03/28/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1252 HIDDEN LAKE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLOOMFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48302-1955
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-258-1967
Provider Business Mailing Address Fax Number:
248-258-5868

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7575 GRAND RIVER RD
Provider Second Line Business Practice Location Address:
STE 111
Provider Business Practice Location Address City Name:
BRIGHTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48114-9390
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-844-7744
Provider Business Practice Location Address Fax Number:
810-844-7725
Provider Enumeration Date:
06/09/2005

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: 207W00000X , with the licence number:  4301040778 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152W00000X , with the licence number: 4301040778 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: RC040778 . This is a "BCBS REFERRING" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1804701481 . This is a "BCBS INDIV PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4301040778 . This is a "STATE LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 2681557 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 900D710610 . This is a "BCBSM OPTOMETRIC GROUP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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