Basic Information
| Provider Information | |||||||||
| NPI: | 1205967445 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EDWARD H CLARKE MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 147 W GRAY ST | ||||||||
| Address2: | |||||||||
| City: | ELMIRA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 149013017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077336698 | ||||||||
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| Practice Location | |||||||||
| Address1: | 147 W GRAY ST | ||||||||
| Address2: | |||||||||
| City: | ELMIRA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 149013017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077336698 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | CLARKE | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6077336698 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 1039991 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00685823 | 05 | NY | MEDICAID |