Timothy Jerum Clark, NP

Primary specialty

Family Nurse PractitionerTaxonomy code 363LF0000X

License

SP017303 Issued in PA

Practice address

246 Hart Ave
Staten Island, NY 10310-3022

Phone

(347) 306-8981

NPI assigned

Apr 22, 2017

Sex

Male

Sole proprietor

No

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

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in PA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Nurse Practitioner

State licenses

Practice roles

Locations

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.

• Family Care Centers Inc.

  dba Lehigh Valley Physician Group - Pocono

  • Internal Medicine Physician
  • E Stroudsburg, PA
  • NPI 1669563037
  Medicare reassignment NPD
• Family Care Centers Inc

  dba LVPG ExpressCare Pocono

  • Family Medicine Physician
  • East Stroudsburg, PA
  • NPI 1316409626
  NPD

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

{
    "created_epoch": "1492819200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1617062400000",
    "number": "1518492008",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "246 HART AVE",
            "city": "STATEN ISLAND",
            "state": "NY",
            "postal_code": "103103022",
            "telephone_number": "347-306-8981"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "246 HART AVE",
            "city": "STATEN ISLAND",
            "state": "NY",
            "postal_code": "103103022",
            "telephone_number": "347-306-8981"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLARK",
        "first_name": "TIMOTHY",
        "middle_name": "JERUM",
        "name_prefix": "Mr.",
        "credential": "NP",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2017-04-22",
        "last_updated": "2021-03-30",
        "certification_date": "2021-03-30",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "PA",
            "license": "SP017303",
            "primary": true
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "NY",
            "license": "341667",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Jessica Clark, LCSW
• Jodi Clark
• Laura Clark
• Lindsey M Clark, MSED
• Sarah Clark, RN
• William A Clark, RN
• Brian Clarke
• Collette Andrea Clarke, RN
• Connie Erin Clarke, LCSW
• David Charles Clarke, OTR/L

• Family Nurse Practitioner in Staten Island, NY
• Providers in Staten Island, NY by specialty
• Family Nurse Practitioner in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 30, 2021; 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.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.