NPIMap

Individual provider Active NPI

Clancy J Clark, MD

  • Surgery Physician
  • Seattle, WA
National Provider Identifier
1053455444
Registry record updated Dec 13, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Surgery PhysicianTaxonomy code 208600000X
License
MD61617432 Issued in WA
Practice address
1100 9TH Ave
Seattle, WA 98101
Phone
(206) 624-1144
NPI assigned
Feb 18, 2007
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Dec 13, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Surgery Physician 208600000X 2012-01216 NC
Surgical Oncology Physician 2086X0206X 2012-01216 NC
Surgery Physician 208600000X MD61617432 WA Primary

Addresses

Primary practice location

1100 9TH Ave
Seattle, WA 98101

Mailing address

2450 Greenbrier Rd
Winston Salem, NC 27104-2108
Phone (336) 480-8064

Other practice location 1

Medical Center Blvd
Winston Salem, NC 27157-0001
Phone (336) 716-9272

Other identifiers 1

IdentifierTypeStateIssuer
5920754MedicaidNC

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NC, WA2 enrollments
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
I20120907000736 NC Practitioner - General SurgeryPractitioner - Surgical Oncology 3870627979
I20241204001807 WA Practitioner - Other (Physician)Practitioner - General SurgeryPractitioner - Surgical Oncology 3870627979 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Undefined Physician Type (Specify)Also: General Surgery, Surgical Oncology
Education
Ohio State University College of Medicine, 2004
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Virginia Mason Medical CenterGroup PAC ID 9830002617, 867 clinicians
Franciscan Medical GroupGroup PAC ID 0547173866, 1,400 clinicians

Practice addresses (Care Compare)

1100 9TH Ave
Seattle, WA 98101-2756
Phone (206) 223-6600

1708 Yakima Ave
Suite 105
Tacoma, WA 98405-5300
Phone (253) 552-1200

Hospital & facility affiliations

Procedures performed for Medicare patients

ProcedureNumber of procedures
Colonoscopy1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
2012-01216NCMDSurgery Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Virginia Mason Medical Center Surgery CurrentSince Dec 19, 2024 Accepting new patients
Virginia Mason Medical Center Surgery CurrentSince Dec 19, 2024 Accepting new patients
Virginia Mason Medical Center Current Accepting new patients
Franciscan Medical Group CurrentSince Apr 2, 2025 Accepting new patients
Franciscan Medical Group Surgery CurrentSince Apr 2, 2025 Accepting new patients
Virginia Mason Medical Center Past Accepting new patients
Franciscan Medical Group Past Accepting new patients
Franciscan Medical Group Past Accepting new patients

Locations

380 Winslow Way E
Bainbridge Island, WA 98110
Phone (206) 842-5632

925 Seneca St
Seattle, WA 98101
Phone (206) 341-0860

1100 9th Ave
Seattle, WA 98101
Phone (206) 223-6980

1708 Yakima Ave
Ste 105
Tacoma, WA 98405
Phone (253) 426-4420

1812 S J St
Ste 120
Tacoma, WA 98405
Phone (253) 428-2200

1708 Yakima Ave
Ste 112
Tacoma, WA 98405
Phone (253) 572-5115

Networks

  • WA PPO C-SNP
  • devoted network organization-83621310-88c0-4660-8f8d-b8ea8f4dc04e

Interoperability endpoints

  • FHIR API: https://fhir-myrecord.cerner.com/r4/66ad9a50-d7f7-4c21-b933-2ba90047388e/

Organizations & group practices 8

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 12

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1171756800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1734048000000",
    "number": "1053455444",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2450 GREENBRIER RD",
            "city": "WINSTON SALEM",
            "state": "NC",
            "postal_code": "271042108",
            "telephone_number": "336-480-8064"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1100 9TH AVE",
            "city": "SEATTLE",
            "state": "WA",
            "postal_code": "98101",
            "telephone_number": "206-624-1144"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "Medical Center Blvd",
            "address_purpose": "LOCATION",
            "city": "Winston Salem",
            "state": "NC",
            "postal_code": "271570001",
            "country_code": "US",
            "telephone_number": "336-716-9272",
            "fax_number": "336-716-6637",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "CLARK",
        "first_name": "CLANCY",
        "middle_name": "J",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2007-02-18",
        "last_updated": "2024-12-13",
        "certification_date": "2024-12-13",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208600000X",
            "taxonomy_group": "",
            "desc": "Surgery",
            "state": "NC",
            "license": "2012-01216",
            "primary": false
        },
        {
            "code": "2086X0206X",
            "taxonomy_group": "",
            "desc": "Surgery, Surgical Oncology",
            "state": "NC",
            "license": "2012-01216",
            "primary": false
        },
        {
            "code": "208600000X",
            "taxonomy_group": "",
            "desc": "Surgery",
            "state": "WA",
            "license": "MD61617432",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "5920754",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Seattle, WA

Sources for this page

Verify at the official NPI Registry.