NPIMap

Individual provider Active NPI

Charles Clark III, MD

  • Orthopaedic Surgery Physician
  • Nampa, ID
National Provider Identifier
1114346434
Registry record updated Jan 13, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Orthopaedic Surgery PhysicianTaxonomy code 207X00000X
License
M-15579 Issued in ID
Practice address
9850 W St Lukes Dr
Nampa, ID 83687-7912
Phone
(208) 706-2663
Fax
(208) 489-4300
NPI assigned
Apr 15, 2014
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jan 13, 2021

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Orthopaedic Surgery Physician 207X00000X M-15579 ID Primary

Addresses

Primary practice location

9850 W St Lukes Dr
Nampa, ID 83687-7912

Mailing address

2718 W Jetton Ave
Tampa, FL 33629-5327
Phone (813) 784-0002

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ID
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
I20210309001862 ID Practitioner - Orthopedic Surgery 2264769769 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Orthopedic Surgery
Education
University of Florida College of Medicine, 2014
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
St Lukes Clinic-Treasure Valley LLCGroup PAC ID 4981878402, 1,155 clinicians

Practice addresses (Care Compare)

2619 W Fairview Ave
Boise, ID 83702-6722
Phone (208) 706-2676

608 W Hays St
Boise, ID 83702-5511
Phone (208) 381-5970

610 W Hays St
Boise, ID 83702-5511
Phone (208) 381-5970

9580 W St Lukes Dr
Nampa, ID 83687-7912
Phone (208) 505-2711

9850 St Lukes Dr
Nampa, ID 83687-7912

9850 W St Luke's Dr
Nampa, ID 83687-7912

Hospital & facility affiliations

Procedures performed for Medicare patients

ProcedureNumber of procedures
Upper limb (arm) arthroscopy (minimally invasive joint repair)18

National Provider Directory

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

State licenses

LicenseStateTypeSpecialty
M-15579IDMDOrthopaedic Surgery Physician

Practice roles

OrganizationSpecialtyStatusNew patients
St Lukes Clinic-Treasure Valley LLC CurrentSince Feb 4, 2021 Accepting new patients
St Lukes Regional Medical Center Past Accepting new patients

Locations

190 E Bannock St
Boise, ID 83712
Phone (208) 381-2378

610 W Hays St
Boise, ID 83702
Phone (208) 345-3530

9850 W St Lukes Dr
Nampa, ID 83687
Phone (208) 205-7282

9850 W St Lukes Dr
Ste 215
Nampa, ID 83687
Phone (208) 489-1983

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 11

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": "1397520000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1610496000000",
    "number": "1114346434",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2718 W JETTON AVE",
            "city": "TAMPA",
            "state": "FL",
            "postal_code": "336295327",
            "telephone_number": "813-784-0002"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "9850 W ST LUKES DR",
            "city": "NAMPA",
            "state": "ID",
            "postal_code": "836877912",
            "telephone_number": "208-706-2663",
            "fax_number": "208-489-4300"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLARK",
        "first_name": "CHARLES",
        "name_suffix": "III",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2014-04-15",
        "last_updated": "2021-01-13",
        "certification_date": "2021-01-07",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207X00000X",
            "taxonomy_group": "",
            "desc": "Orthopaedic Surgery",
            "state": "ID",
            "license": "M-15579",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Nampa, ID

Sources for this page

Verify at the official NPI Registry.