1275517831 NPI number — CHAD MICHAEL CLARK MD

Table of content: CHAD MICHAEL CLARK MD (NPI 1275517831)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275517831 NPI number — CHAD MICHAEL CLARK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
CHAD
Provider Middle Name:
MICHAEL
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:
1275517831
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/14/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7055
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RENO
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89510-7055
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-867-8021
Provider Business Mailing Address Fax Number:
704-864-4606

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1155 MILL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RENO
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89502-1576
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-982-5000
Provider Business Practice Location Address Fax Number:
775-982-3900
Provider Enumeration Date:
12/06/2005

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: 2085R0202X , with the licence number:  25106 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3616084 . This is a "AETNA HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7095608 . This is a "AETNA PPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 560988142 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 804966 . This is a "PARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: N0019C , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: D4989 . This is a "MEDCOST" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00183056 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1377R . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 891377R , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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