1962470823 NPI number — ERIN LOUISE CLARK MD

Table of content: ERIN LOUISE CLARK MD (NPI 1962470823)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962470823 NPI number — ERIN LOUISE CLARK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
ERIN
Provider Middle Name:
LOUISE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BALDEN
Provider Other First Name:
ERIN
Provider Other Middle Name:
LOUISE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1962470823
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2817 REILLY ROAD
Provider Second Line Business Mailing Address:
WOMACK ARMY MEDICAL CENTER MCXC-COD CREDENTIALS
Provider Business Mailing Address City Name:
FORT BRAGG
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-907-8922
Provider Business Mailing Address Fax Number:
910-907-6069

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
WOMACK ARMY MEDICAL CENTER
Provider Second Line Business Practice Location Address:
DEPT OF MEDICINE
Provider Business Practice Location Address City Name:
FT BRAGG
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-907-8690
Provider Business Practice Location Address Fax Number:
910-907-8360
Provider Enumeration Date:
03/08/2006

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: 207R00000X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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