Basic Information
| Provider Information | |||||||||
| NPI: | 1629278882 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOWELL F. CLARK MD PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 212 S FLORIDA ST | ||||||||
| Address2: | |||||||||
| City: | BUSHNELL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335136703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527871600 | ||||||||
| FaxNumber: | 3527933282 | ||||||||
| Practice Location | |||||||||
| Address1: | 212 S FLORIDA ST | ||||||||
| Address2: | |||||||||
| City: | BUSHNELL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335136703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527871600 | ||||||||
| FaxNumber: | 3527933282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2007 | ||||||||
| LastUpdateDate: | 12/21/2007 | ||||||||
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| AuthorizedOfficialLastName: | FOLK | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3527871600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | ED.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME45090 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 33972 | 01 | FL | BCBS OF FLORIDA GROUP ID | OTHER |