Basic Information
| Provider Information | |||||||||
| NPI: | 1033111752 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 660 BEAVER CREEK CIR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MAUMEE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435371745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198916221 | ||||||||
| FaxNumber: | 4198933394 | ||||||||
| Practice Location | |||||||||
| Address1: | 660 BEAVER CREEK CIR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MAUMEE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435371745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198916221 | ||||||||
| FaxNumber: | 4198933394 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2005 | ||||||||
| LastUpdateDate: | 04/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 35080735 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 7534411 | 01 | OH | AETNA | OTHER | 000000246226 | 01 | OH | ANTHEM | OTHER | 12-04381 | 01 | OH | UHC | OTHER | 04219 | 01 | OH | PARAMOUNT | OTHER | 2333264 | 05 | OH | MEDICAID |