Provider Demographics
NPI:1861521031
Name:CLARK CENTER FOR COMPREHENSIVE MEDICINE P.C.
Entity type:Organization
Organization Name:CLARK CENTER FOR COMPREHENSIVE MEDICINE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:GODFREY
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-367-1205
Mailing Address - Street 1:29521 FORD RD
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48135-2319
Mailing Address - Country:US
Mailing Address - Phone:734-367-1205
Mailing Address - Fax:734-367-1214
Practice Address - Street 1:29521 FORD RD
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:MI
Practice Address - Zip Code:48135
Practice Address - Country:US
Practice Address - Phone:734-367-1205
Practice Address - Fax:734-367-1214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DB2730OtherMEDICARE RAIL ROAD
110H221360OtherBLUE CROSS BLUE SHIELD
DB2730OtherMEDICARE RAIL ROAD
0N89810Medicare PIN