NPIMap

Individual provider Active NPI

Clark Calvin Anderson, MD

  • Student in an Organized Health Care Education/Training Program
  • San Antonio, TX
National Provider Identifier
1104485770
Registry record updated Jun 25, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Student in an Organized Health Care Education/Training ProgramTaxonomy code 390200000X
Practice address
4502 Medical Dr
San Antonio, TX 78229
Phone
(920) 460-8927
NPI assigned
Jun 7, 2019
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jun 25, 2024

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

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine Physician 207R00000X NONE NC
Internal Medicine Physician 207R00000X 0101281056 VA
Student in an Organized Health Care Education/Training Program 390200000X Primary

Addresses

Primary practice location

4502 Medical Dr
San Antonio, TX 78229

Mailing address

9666 Criswell CRK
San Antonio, TX 78251-3537
Phone (920) 460-8927

Other practice location 1

1 Medical Center Blvd
Winston Salem, NC 27157-0001
Phone (336) 716-2011

Other practice location 2

210 Medical Park Blvd Ste 100
Petersburg, VA 23805-9348
Phone (804) 765-5850

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20240808000624 VA Practitioner - Radiation Oncology 6608103841 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Radiation Oncology
Education
Texas Tech University Health Science Center School of Medicine, 2019
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Bon Secours Medical Group Richmond Specialty Care LLCGroup PAC ID 8022440056, 350 clinicians

Practice addresses (Care Compare)

1510 N 28TH St
Richmond, VA 23223-5311

210 Medical Park Blvd
Petersburg, VA 23805-9348

40 Medical Park Blvd
Petersburg, VA 23805-9289

Hospital & facility affiliations

  • Bon Secours Southside Medical Center Hospital, Petersburg, VA, CCN 490067
  • Bon Secours St Francis Medical Center Hospital, Midlothian, VA, CCN 490136

National Provider Directory

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

State licenses

LicenseStateTypeSpecialty
0101281056VAMDInternal Medicine Physician
NONENCMDPediatrics Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Bon Secours Medical Group Richmond Specialty Care LLC CurrentSince Aug 11, 2024 Accepting new patients
Bon Secours Medical Group Richmond Specialty Care LLC CurrentSince Aug 11, 2024 Accepting new patients

Locations

210 Medical Park Blvd
Ste 100
Petersburg, VA 23805
Phone (804) 765-5850

1510 N 28th St
Ste 110
Richmond, VA 23223
Phone (804) 545-2304

Interoperability endpoints

  • Direct secure messaging: canderson2614908@direct.bsmhealth.org

Organizations & group practices 2

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": "1559865600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1719273600000",
    "number": "1104485770",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "9666 CRISWELL CRK",
            "city": "SAN ANTONIO",
            "state": "TX",
            "postal_code": "782513537",
            "telephone_number": "920-460-8927"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4502 MEDICAL DR",
            "city": "SAN ANTONIO",
            "state": "TX",
            "postal_code": "78229",
            "telephone_number": "920-460-8927"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1 Medical Center Blvd",
            "address_purpose": "LOCATION",
            "city": "Winston Salem",
            "state": "NC",
            "postal_code": "271570001",
            "country_code": "US",
            "telephone_number": "336-716-2011",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "210 Medical Park Blvd Ste 100",
            "address_purpose": "LOCATION",
            "city": "Petersburg",
            "state": "VA",
            "postal_code": "238059348",
            "country_code": "US",
            "telephone_number": "804-765-5850",
            "fax_number": "804-765-5870",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "ANDERSON",
        "first_name": "CLARK",
        "middle_name": "CALVIN",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2019-06-07",
        "last_updated": "2024-06-25",
        "certification_date": "2023-07-18",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "NC",
            "license": "NONE",
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "VA",
            "license": "0101281056",
            "primary": false
        },
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in San Antonio, TX

Sources for this page

Verify at the official NPI Registry.