1790828648 NPI number — WILLIAM CLARK MEDICAL GROUP PA

Table of content: (NPI 1790828648)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790828648 NPI number — WILLIAM CLARK MEDICAL GROUP PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILLIAM CLARK MEDICAL GROUP PA
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:
1790828648
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/01/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 670188
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77267-0188
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-272-0888
Provider Business Mailing Address Fax Number:
281-272-0895

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
133 NORTHPOINT DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77060-3207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-272-0888
Provider Business Practice Location Address Fax Number:
713-695-7765
Provider Enumeration Date:
02/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CLARK
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
281-272-0888

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  E4818 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1760445704 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 130727402 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 130727403 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1790828648 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 083833601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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