1780769018 NPI number — DR. R. RAY CLARK PH.D.

Table of content: DR. R. RAY CLARK PH.D. (NPI 1780769018)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780769018 NPI number — DR. R. RAY CLARK PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
R. RAY
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CLARK
Provider Other First Name:
R RAY
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1780769018
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/05/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8128
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PITTSBURGH
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15217-0128
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
412-621-0551
Provider Business Mailing Address Fax Number:
412-621-6414

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5725 FORWARD AVE
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
PITTSBURGH
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15217-2255
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
412-621-0551
Provider Business Practice Location Address Fax Number:
412-621-6414
Provider Enumeration Date:
10/26/2006

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: 103TC0700X , with the licence number:  PS-008392-L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0016409990005 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00180561 . This is a "BCBS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: S46121 . This is a "HIGHMARK" identifier . This identifiers is of the category "OTHER".




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