1336249341 NPI number — BARRY A CLARK MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336249341 NPI number — BARRY A CLARK MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

CLARK

Provider First Name:

BARRY

Provider Middle Name:

A

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

MD

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:

1336249341

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

02/28/2012

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

1B MAIN ST

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

WELLSBORO

Provider Business Mailing Address State Name:

PA

Provider Business Mailing Address Postal Code:

16901-1601

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

570-724-7100

Provider Business Mailing Address Fax Number:

570-724-1501

Provider First Line Business Practice Location Address:

1B MAIN ST

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

WELLSBORO

Provider Business Practice Location Address State Name:

PA

Provider Business Practice Location Address Postal Code:

16901-1601

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

570-724-7100

Provider Business Practice Location Address Fax Number:

570-724-1501

Provider Enumeration Date:

09/22/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 208000000X , with the licence number:  MD029130E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 0065299000 . This is a "PERSONAL CHOICE" identifier . This identifiers is of the category "OTHER".
• Identifier: 01032526 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
• Identifier: 13037 . This is a "GHP" identifier . This identifiers is of the category "OTHER".
• Identifier: 0009089200001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
• Identifier: 304219 . This is a "UPHC" identifier . This identifiers is of the category "OTHER".
• Identifier: 4623938 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
• Identifier: 002502 . This is a "FIRST PRIORITY" identifier . This identifiers is of the category "OTHER".
• Identifier: 2603062 . This is a "GHI" identifier . This identifiers is of the category "OTHER".
• Identifier: 0606293 . This is a "ACCESS CARE II" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 39D0980728 . This is a "CLEA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 794397 . This is a "HEALTH CARE ADVANTAGE" identifier . This identifiers is of the category "OTHER".
• Identifier: CX28 . This is a "HEALTH ASSURANCE" identifier . This identifiers is of the category "OTHER".
• Identifier: 070598 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".