Basic Information
Provider Information | |||||||||
NPI: | 1053387936 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CLARK | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | E | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4 SHERIDAN RD | ||||||||
Address2: |   | ||||||||
City: | FAIRFIELD | ||||||||
State: | ME | ||||||||
PostalCode: | 049373314 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2078615000 | ||||||||
FaxNumber: | 2078615001 | ||||||||
Practice Location | |||||||||
Address1: | 4 SHERIDAN DRIVE | ||||||||
Address2: |   | ||||||||
City: | FAIRFIELD | ||||||||
State: | ME | ||||||||
PostalCode: | 04937 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2078615000 | ||||||||
FaxNumber: | 2078615001 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/28/2006 | ||||||||
LastUpdateDate: | 10/16/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 013687 | ME | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1053387936 | 05 | ME |   | MEDICAID | 272100099 | 05 | ME |   | MEDICAID |