Basic Information
| Provider Information | |||||||||
| NPI: | 1851409007 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | FRANK | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 TRILLIUM WAY STE 205 | ||||||||
| Address2: | |||||||||
| City: | CORBIN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407018445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065232140 | ||||||||
| FaxNumber: | 6065232547 | ||||||||
| Practice Location | |||||||||
| Address1: | TRILLIUM WAY | ||||||||
| Address2: | |||||||||
| City: | CORBIN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407018445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065281212 | ||||||||
| FaxNumber: | 6065232547 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 36432 | KY | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 000000200592 | 01 | KY | ANTHEM | OTHER | 64044878 | 05 | KY | MEDICAID |