Robert B Clark Jr MD LLC

Primary specialty

SpecialistTaxonomy code 174400000X

License

020521 Issued in GA

Legal business name

ROBERT B CLARK JR MD LLC

Practice address

1811 Manning Drive
Vidalia, GA 30474

Phone

(912) 537-6634

Fax

(912) 537-1909

NPI assigned

Jul 5, 2006

Last updated

Mar 27, 2013By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Priscilla E Edge

Title

Credentialing

Phone

(912) 537-8691

Specialties & licenses 1

Addresses

Other identifiers 4

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

{
    "created_epoch": "1152057600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1364342400000",
    "number": "1326079039",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1811 MANNING DRIVE",
            "city": "VIDALIA",
            "state": "GA",
            "postal_code": "30474",
            "telephone_number": "912-537-6634",
            "fax_number": "912-537-1909"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1811 MANNING DRIVE",
            "city": "VIDALIA",
            "state": "GA",
            "postal_code": "30474",
            "telephone_number": "912-537-6634",
            "fax_number": "912-537-1909"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ROBERT B CLARK JR MD LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-05",
        "last_updated": "2013-03-27",
        "status": "A",
        "authorized_official_last_name": "EDGE",
        "authorized_official_first_name": "PRISCILLA",
        "authorized_official_middle_name": "E",
        "authorized_official_title_or_position": "CREDENTIALING",
        "authorized_official_telephone_number": "912-537-8691"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Specialist",
            "state": "GA",
            "license": "020521",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICAID REFERRAL",
            "identifier": "449866340",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000177713D",
            "state": "GA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PERSONAL NPI NUMBER 1144289349",
            "identifier": "1144289349",
            "state": "GU"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE GROUP NUMBER",
            "identifier": "GRP7739",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Restore Wellness and Aesthetics
• Heidi Marie Reuschling, DC
• Walter J Revell Jr., MD
• Jennifer Richter, LCSW
• Amanda Dawn Rizzo, M. ED. , BCBA
• Robert S Riddick MDPC (Riddick Surgical Services)
• Michael David Robinson, MD
• John W Robison, MD
• Ronald B. Yancey, P.C. (Yancey Eye Center)
• Timothy Roose, CRNA

• Specialist in Vidalia, GA
• Providers in Vidalia, GA by specialty
• Specialist in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 27, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.