Basic Information
| Provider Information | |||||||||
| NPI: | 1477572097 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | LYLE | ||||||||
| MiddleName: | ARTHUR | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 E LA HARPE ST | ||||||||
| Address2: | |||||||||
| City: | KIRKSVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 635014520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6606651962 | ||||||||
| FaxNumber: | 6606653989 | ||||||||
| Practice Location | |||||||||
| Address1: | 141 COMMUNICATION DRIVE | ||||||||
| Address2: | |||||||||
| City: | HANNIBAL | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737957342 | ||||||||
| FaxNumber: | 5732483080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 06/04/2014 | ||||||||
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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 | 2084P0800X | R8E55 | MO | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 208444604 | 05 | MO | MEDICAID |