Basic Information
| Provider Information | |||||||||
| NPI: | 1518985837 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | NATHAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 ELMWOOD AVE | ||||||||
| Address2: | BOX 604 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146420001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852755982 | ||||||||
| FaxNumber: | 5857560169 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 ELMWOOD AVE | ||||||||
| Address2: | BOX 604 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146420001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852755982 | ||||||||
| FaxNumber: | 5857560169 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 207L00000X | 228078 | NY | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 02410286 | 05 | NY | MEDICAID | G0189393590 | 01 | NY | BLUE CHOICE GROUP# | OTHER | P00013266 | 01 | NY | RAILROAD MEDICARE PROVIDE | OTHER | 5397952 | 01 | NY | GHI PROVIDER# | OTHER | 00372225 | 05 | NY | MEDICAID | CC0135 | 01 | NY | RAILROAD MEDICARE GROUP# | OTHER | MDH505 | 01 | NY | PREFERRED CARE# | OTHER | 2222 | 01 | NY | BLUE SHIELD GROUP# | OTHER | 7829472 | 01 | NY | AETNA PROVIDER# | OTHER |