1861788101 NPI number — DR. KYLIE CLARK M.D.

Table of content: DR. KYLIE CLARK M.D. (NPI 1861788101)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861788101 NPI number — DR. KYLIE CLARK M.D.

Organization/Personal Information

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

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:
1861788101
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/22/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5050 NE HOYT ST
Provider Second Line Business Mailing Address:
SUITE B55
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97213-2991
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-233-5393
Provider Business Mailing Address Fax Number:
503-659-8984

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5050 NE HOYT ST
Provider Second Line Business Practice Location Address:
SUITE B55
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97213-2991
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-233-5393
Provider Business Practice Location Address Fax Number:
503-659-8984
Provider Enumeration Date:
06/24/2011

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: 208000000X , with the licence number:  MD168562 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 390200000X , with the licence number: 2011018538 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 500674850 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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