Kellie Marie Clark, MD
Individual provider Active NPI Family Medicine Physician · Middleville, MI
NPI 1619585403 · NPPES record last updated Sep 11, 2024
Key facts
- NPI
- 1619585403
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Family Medicine Physician 207Q00000X
- License
- 4301511876 (MI)
- Practice address
- 490 Edward St
Middleville, MI 49333-9131 - Phone
- (269) 795-4434
- Fax
- (269) 795-4271
- NPI assigned
- Jul 17, 2020
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 9
Hospital & facility affiliations 2
Medicare Care Compare profile
- Specialty
- Family Practice
- Education
- Other, 2021
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Group practices
- Pennock Hospital
Practice addresses (Care Compare)
490 Edward St
Corewell Health Pennock Hospital
Middleville, MI 49333-9131
Phone (269) 795-4434
Hospital & facility affiliations
- Corewell Health Pennock Hospital
- Spectrum Health
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MI
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20240626000640 | MI | Practitioner - Family Practice | 8426459942 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Medicine
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Pennock Hospital | Family Medicine | Current |
Accepting new patients |
| Pennock Hospital | Current |
Accepting new patients | |
| Spectrum Health Primary Care Partners | Past | Accepting new patients |
Locations
100 Michigan St NE
#845
Grand Rapids, MI 49503
Phone (616) 391-8242
1005 W Green St
Ste 300
Hastings, MI 49058
Phone (269) 948-8411
490 Edward St
Middleville, MI 49333
Phone (269) 795-4434
Interoperability endpoints
- kclark288046@epic00.corewelldirect.org
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 4301511876 | MI | Yes |
Addresses
Primary practice location
490 Edward St
Middleville, MI 49333-9131
Mailing address
100 Michigan St NE # Mc845
Grand Rapids, MI 49503-2560
Other providers in Middleville, MI
- Gina Marie Biersack
- Tracy M Blakeman
- Amanda Whitney Bowman
- Melinda Kay Bruxvoort
- Taylor Carter
- Angela Marie Compton
- Contemporarycare at Home, LLC
- Coordinated Pharmacist Care PLLC
- Craft Chiropractic Center PC
- Crossroads Counseling & Consultation Services, LLC
All providers in Middleville, MI · Family Medicine Physician in Michigan
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Sep 11, 2024. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.