Basic Information
| Provider Information | |||||||||
| NPI: | 1053373399 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60359 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432373378 | ||||||||
| FaxNumber: | 8432375073 | ||||||||
| Practice Location | |||||||||
| Address1: | 420 N CENTER ST | ||||||||
| Address2: | |||||||||
| City: | HICKORY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286015046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432373378 | ||||||||
| FaxNumber: | 8432375073 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2006 | ||||||||
| LastUpdateDate: | 03/17/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 200300020 | NC | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 891293C | 05 | NC | MEDICAID | 1293C | 01 | NC | BCBS | OTHER | P00251742 | 01 | NC | RAILROAD MEDICARE | OTHER |