Kirby Dwight Clark, M.D.

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

License

45690 Issued in MN

Practice address

Ufp Phalen Village Clinic
1414 Maryland Avenue East
Saint Paul, MN 55106

Phone

(651) 772-3461

Fax

(651) 772-2605

NPI assigned

Jun 29, 2006

Sex

Male

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Other identifiers 9

Medicare fee-for-service enrollment

Enrolled in MN

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Specialty

Family Practice

Education

University of Minnesota Medical School, 2001

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Fairview ClinicsGroup PAC ID 7113830142, 799 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• M Health Fairview St John'S Hospital Hospital, Maplewood, MN, CCN 240210
• M Health Fairview Woodwinds Hospital Hospital, Woodbury, MN, CCN 240213

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: kclark285650@fairview.direct-ci.com

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.

• Fairview Clinics

  • Primary Care Clinic/Center
  • Minneapolis, MN
  • NPI 1346432218
  Medicare reassignment Care Compare group NPD
• Fairview Express Care

  • Multi-Specialty Clinic/Center
  • Minneapolis, MN
  • NPI 1053952606
  Medicare reassignment NPD
• Healtheast St. John'S Hospital

  • General Acute Care Hospital
  • Maplewood, MN
  • NPI 1447218482
  Medicare reassignment NPD
• Fairview Clinics

  • Primary Care Clinic/Center
  • Saint Paul, MN
  • NPI 1396552147
  NPD
• Fairview Express Care

  • General Practice Physician
  • Edina, MN
  • NPI 1831707207
  NPD
• Fairview Clinics

  • Multi-Specialty Clinic/Center
  • Maple Grove, MN
  • NPI 1841315165
  NPD (past)
• University of Minnesota Physicians

  • Multi-Specialty Clinic/Center
  • Minneapolis, MN
  • NPI 1477598118
  NPD (past)
• Cardiothoracic Surgery Clinic of North Ms

  • Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
  • Tupelo, MS
  • NPI 1154533321
  NPD (past)

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

• Healtheast St. John'S Hospital

  • General Acute Care Hospital
  • Maplewood, MN
  • NPI 1447218482
  Care Compare affiliation
• Healtheast Woodwinds Hospital

  • General Acute Care Hospital
  • Woodbury, MN
  • NPI 1356309322
  Care Compare affiliation

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

{
    "created_epoch": "1151539200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183939200000",
    "number": "1447288311",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "UFP PHALEN VILLAGE CLINIC",
            "address_2": "1414 MARYLAND AVENUE EAST",
            "city": "SAINT PAUL",
            "state": "MN",
            "postal_code": "55106",
            "telephone_number": "651-772-3461",
            "fax_number": "651-772-2605"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "UFP PHALEN VILLAGE CLINIC",
            "address_2": "1414 MARYLAND AVENUE EAST",
            "city": "SAINT PAUL",
            "state": "MN",
            "postal_code": "55106",
            "telephone_number": "651-772-3461",
            "fax_number": "651-772-2605"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLARK",
        "first_name": "KIRBY",
        "middle_name": "DWIGHT",
        "name_prefix": "Dr.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-06-29",
        "last_updated": "2007-07-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "MN",
            "license": "45690",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CHAMPUS",
            "identifier": "A024",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "HEALTHPARTNERS",
            "identifier": "HP54853",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICA CHOICE & PRIMARY",
            "identifier": "01-21349",
            "state": "MN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0567727",
            "state": "IA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "128460600",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ARAZ",
            "identifier": "2374581",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "676T8CL",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PREFERRED ONE",
            "identifier": "1044612",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UCARE",
            "identifier": "135432",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• David James Clark
• Elizabeth Ann Clark, P.T.
• Jessica Marion Clark, PMHNP
• John Lewis Clark, LICSW
• Kali Jo Clark, RN
• Mary A Clark
• Molly Regina Marie Clark, MD
• Renee Lynn Clark, DNP, CNM
• Sandra Louise Clark, NCACII, LADC, CCJP
• Mary Colleen Clarke, MA

• Family Medicine Physician in Saint Paul, MN
• Providers in Saint Paul, MN by specialty
• Family Medicine Physician in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 9, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.