1386676211 NPI number — PRINCE AVENUE PRIMARY CARE, L.L.C.

Table of content: DR. ROBERT MILTON CLARK DO (NPI 1386675890)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386676211 NPI number — PRINCE AVENUE PRIMARY CARE, L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRINCE AVENUE PRIMARY CARE, L.L.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1386676211
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/28/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
892 PRINCE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATHENS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30606-2724
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-227-2027
Provider Business Mailing Address Fax Number:
706-227-2433

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
892 PRINCE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATHENS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30606-2724
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-227-2027
Provider Business Practice Location Address Fax Number:
706-227-2433
Provider Enumeration Date:
07/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GIBSON
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
B
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
706-227-2027

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  015584 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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