1588866834 NPI number — BRENDAN JAMES CLARKE

Table of content: BRENDAN JAMES CLARKE (NPI 1588866834)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588866834 NPI number — BRENDAN JAMES CLARKE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARKE
Provider First Name:
BRENDAN
Provider Middle Name:
JAMES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1588866834
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26 WARWICK ST # 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOMERVILLE
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02145-3510
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-501-5633
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
206 N MYERS ST APT B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURBANK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91506-2323
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-501-5633
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/31/2007

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: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: LPCC14461 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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