Basic Information
| Provider Information | |||||||||
| NPI: | 1891795985 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | BARRY | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 499 GLOSTER CREEK VLG STE G1 | ||||||||
| Address2: | |||||||||
| City: | TUPELO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 388014751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623772663 | ||||||||
| FaxNumber: | 6623776706 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 MEDICAL PARK DR | ||||||||
| Address2: | |||||||||
| City: | HARTSVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295504765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433833742 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2005 | ||||||||
| LastUpdateDate: | 10/30/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 833 | SC | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 26229 | MS | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0114X | 26229 | MS | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 02537316 | 05 | MS | MEDICAID |