1801976105 NPI number — CHRISTOPHER TIMOTHY CLARK M.D.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801976105 NPI number — CHRISTOPHER TIMOTHY CLARK M.D.

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

CLARK

Provider First Name:

CHRISTOPHER

Provider Middle Name:

TIMOTHY

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

M.D.

Provider Gender Code:

M

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:

1801976105

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

09/28/2010

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

20575 ERIE RD

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

ROCKY RIVER

Provider Business Mailing Address State Name:

OH

Provider Business Mailing Address Postal Code:

44116-1414

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

216-476-7108

Provider Business Mailing Address Fax Number:

216-476-7109

Provider First Line Business Practice Location Address:

1924 ALCOA HWY

Provider Second Line Business Practice Location Address:

DEPARTMENT OF PATHOLOGY

Provider Business Practice Location Address City Name:

KNOXVILLE

Provider Business Practice Location Address State Name:

TN

Provider Business Practice Location Address Postal Code:

37920-1511

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

865-305-8994

Provider Business Practice Location Address Fax Number:

865-305-6866

Provider Enumeration Date:

10/17/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207ZP0102X , with the licence number:  35.072415 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207ZP0102X , with the licence number: 38281-020 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207ZP0102X , with the licence number: 44055 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: SY245065068 . This is a "TRICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 000000180176 . This is a "OHIO OPERATING ENGINEERS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 2042373 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
• Identifier: 2042373 . This is a "BCMH" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 340714618011 . This is a "MEDICAL MUTUAL OF OHIO" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 4203908 . This is a "BCBS OF TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
• Identifier: 000000180176 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 1510737 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
• Identifier: P00747161 . This is a "RR MEDICARE PART B" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".