Basic Information
| Provider Information | |||||||||
| NPI: | 1528146586 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | MORRIGAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 115 E 87TH ST | ||||||||
| Address2: | APT. 15E | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 101281136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8666338255 | ||||||||
| FaxNumber: | 7186559672 | ||||||||
| Practice Location | |||||||||
| Address1: | 3400 BAINBRIDGE AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104672404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8666338255 | ||||||||
| FaxNumber: | 7186559672 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 11/19/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | 171055 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01019956 | 05 | NY | MEDICAID |