1871550244 NPI number — JOHN ROSS CLARK

Table of content: JOHN ROSS CLARK (NPI 1871550244)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871550244 NPI number — JOHN ROSS CLARK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
JOHN
Provider Middle Name:
ROSS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1871550244
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/16/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9142
Provider Second Line Business Mailing Address:
MASS GENERAL PHYSICIANS ORGANIZATION INC
Provider Business Mailing Address City Name:
CHARLESTOWN
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02129-9142
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-724-4000
Provider Business Mailing Address Fax Number:
617-643-1915

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
55 FRUIT STREET
Provider Second Line Business Practice Location Address:
YAW 7B MASS GENERAL HOSPITAL
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02114-2696
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-724-4000
Provider Business Practice Location Address Fax Number:
617-643-1915
Provider Enumeration Date:
04/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X , with the licence number:  49154 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6194613 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: J02760 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




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