Basic Information
| Provider Information | |||||||||
| NPI: | 1083934467 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | HAL | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9369 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366910369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514600326 | ||||||||
| FaxNumber: | 2514602846 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 MOBILE INFIRMARY CIR | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366073513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514600326 | ||||||||
| FaxNumber: | 2514602846 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2010 | ||||||||
| LastUpdateDate: | 11/03/2015 | ||||||||
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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 | 2085R0202X | 1256 | AL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 171890 | 05 | AL | MEDICAID | 511-61741 | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER | P01501925 | 01 | RAILROAD MEDICARE | OTHER |