Jeremy J Clark, M.D.

Primary specialty

Gynecology PhysicianTaxonomy code 207VG0400X

License

41069 Issued in KY

Practice address

401 E Chestnut St
Suite 410
Louisville, KY 40202-5700

Phone

(502) 271-5999

Fax

(502) 271-5994

NPI assigned

Jan 22, 2007

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 10

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in CA

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

Obstetrics/Gynecology

Education

Wright State University Boonshoft School of Medicine, 2003

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Southern California Permanente Medical GroupGroup PAC ID 6002729175, 11,250 clinicians

Practice addresses (Care Compare)

Procedures performed for Medicare patients

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

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.

• Southern California Permanente Medical Group

  • Health Maintenance Organization
  • Riverside, CA
  • NPI 1316979834

  CA

  Medicare reassignment Care Compare group NPD
• Southern California Permanente Medical Group

  • Health Maintenance Organization
  • Baldwin Park, CA
  • NPI 1770515280
  Care Compare group
• Southern California Permanente Medical Group

  • Clinical Medical Laboratory
  • N Hollywood, CA
  • NPI 1891873303
  Care Compare group
• Southern California Permanente Medical Group

  • Health Maintenance Organization
  • Woodland Hills, CA
  • NPI 1952333478
  Care Compare group
• Southern California Permanente Medical Group

  • Health Maintenance Organization
  • Santa Clarita, CA
  • NPI 1316409410
  NPD
• The University Gynecological & Obstetrical Foundation, Inc.

  • Specialist
  • Louisville, KY
  • NPI 1497700587
  NPD (past)

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

{
    "created_epoch": "1169424000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1638144000000",
    "number": "1588717417",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "550 S JACKSON ST FL 2",
            "address_2": "DEPT OB/GYN ATT VICKI MASTERSON",
            "city": "LOUISVILLE",
            "state": "KY",
            "postal_code": "402021622"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "401 E CHESTNUT ST",
            "address_2": "SUITE 410",
            "city": "LOUISVILLE",
            "state": "KY",
            "postal_code": "402025700",
            "telephone_number": "502-271-5999",
            "fax_number": "502-271-5994"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLARK",
        "first_name": "JEREMY",
        "middle_name": "J",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2007-01-22",
        "last_updated": "2021-11-29",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207VG0400X",
            "taxonomy_group": "",
            "desc": "Obstetrics & Gynecology, Gynecology",
            "state": "KY",
            "license": "41069",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "HUMANA        PSC",
            "identifier": "000001568F",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ANTHEM - PSC",
            "identifier": "000000542980",
            "state": "KY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PASSPORT SPECIALITY# -FOUNDATION",
            "identifier": "50016302",
            "state": "KY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PASSPORT SPECIALITY - PSC",
            "identifier": "50016301",
            "state": "KY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PASSPORT PCP# - FOUNDATION",
            "identifier": "50017315",
            "state": "KY"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7100013410",
            "state": "KY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AETNA",
            "identifier": "7290926",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200868450",
            "state": "IN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ANTHEM  FOUNDATION",
            "identifier": "000000522820",
            "state": "KY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "HUMANA       FOUNDATION",
            "identifier": "000001172T",
            "state": null
        }
    ],
    "endpoints": [
        {
            "endpointType": "SOAP",
            "endpointTypeDescription": "SOAP URL",
            "endpoint": "https://careepicwest.kp.org:14430/Interconnect-prodcalgateway/wcf/epic.community.hie/xcpdrespondinggatewaysync.svc/scalceq",
            "affiliation": "Y",
            "endpointDescription": "Carequality",
            "affiliationName": "Southern California Permanente Medical Group",
            "use": "HIE",
            "useDescription": "Health Information Exchange (HIE)",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "C-CDA",
            "address_1": "10800 Magnolia Ave",
            "city": "Riverside",
            "state": "CA",
            "country_code": "US",
            "postal_code": "925053043",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Gina Clark, APRN
• Grace Clark, DVM
• Jameel Tamir Clark, M.D.
• Jason S. Clark, D.V.M.
• Jeremy Dustin Clark, M.D.
• Joan Marie Clark, LCSW
• Jordan Clark, DMD
• Joseph Clark, LCADC, CSW
• Joshua Clark
• Joshua Scott Clark, MS, OTR/L

• All providers in Louisville, KY
• Gynecology Physician in Kentucky

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 29, 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.
• 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.