Basic Information
| Provider Information | |||||||||
| NPI: | 1356591523 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLARK RADIOLOGY, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1820 | ||||||||
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| City: | FRANKFORT | ||||||||
| State: | KY | ||||||||
| PostalCode: | 406021820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022263858 | ||||||||
| FaxNumber: | 5022239829 | ||||||||
| Practice Location | |||||||||
| Address1: | 1107 W LEXINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403911169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022263858 | ||||||||
| FaxNumber: | 5022239829 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2008 | ||||||||
| LastUpdateDate: | 09/24/2008 | ||||||||
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| AuthorizedOfficialLastName: | MCQUAIDE | ||||||||
| AuthorizedOfficialFirstName: | BENJAMIN | ||||||||
| AuthorizedOfficialMiddleName: | HOMER | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5022263858 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 28886 | KY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.