NPIMap

Individual provider Active NPI

Edward Petersen Clack, DO

  • Family Medicine Physician
  • Dayton, OH
National Provider Identifier
1659629053
Registry record updated May 3, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
34.011463 Issued in OH
Practice address
5900 N Main St Ste 3
Dayton, OH 45415-3198
Phone
(937) 277-9371
Fax
(937) 277-7734
NPI assigned
Aug 16, 2012
Sex
Male
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on May 3, 2023

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 34.011463 OH Primary

Addresses

Primary practice location

5900 N Main St Ste 3
Dayton, OH 45415-3198

Mailing address

5900 N Main St Ste 3
Dayton, OH 45415-3198
Phone (937) 277-9371

Other identifiers 1

IdentifierTypeStateIssuer
0122811MedicaidOH

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OH
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20141122000327 OH Practitioner - Family PracticePractitioner - Osteopathic Manipulative Medicine 7315186277 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Family PracticeAlso: Osteopathic Manipulative Medicine
Education
At Still University of Health Sciences, College of Osteo Med, Kirksville, 2012
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Shiloh Family Medicine LLCGroup PAC ID 7214051531, 3 clinicians

Practice addresses (Care Compare)

5900 N Main St
Suite 3
Dayton, OH 45415-3106
Phone (937) 277-9371

Hospital & facility affiliations

  • Kettering Homecare Home health agency, Kettering, OH, CCN 367778
  • Fidelity Health Care Home health agency, Moraine, OH, CCN 367160
  • Kettering Health Dayton Hospital, Dayton, OH, CCN 360133
  • Soin Medical Center Hospital, Beaver Creek, OH, CCN 360360
  • Miami Valley Hospital Hospital, Dayton, OH, CCN 360051
  • Kettering Health Main Campus Hospital, Kettering, OH, CCN 360079

Merit-based Incentive Payment System (MIPS)

Final score
89.11 of 100Reported as group
Quality
81.92
Promoting interoperability
100
Improvement activities
40
Cost
81.77

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Osteopathy

Practice roles

OrganizationSpecialtyStatusNew patients
Shiloh Family Medicine LLC Family Medicine CurrentSince Oct 1, 2021 Accepting new patients
Lima Memorial Joint Operating Company Past Accepting new patients
Citran Xray LLC Past Accepting new patients

Locations

5900 N Main St
Ste 3
Dayton, OH 45415
Phone (937) 277-9371

Organizations & group practices 3

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.

Hospital & facility affiliations 6

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

NPI Registry JSON

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

{
    "created_epoch": "1345075200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1683072000000",
    "number": "1659629053",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5900 N MAIN ST STE 3",
            "city": "DAYTON",
            "state": "OH",
            "postal_code": "454153198",
            "telephone_number": "937-277-9371",
            "fax_number": "937-277-7734"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5900 N MAIN ST STE 3",
            "city": "DAYTON",
            "state": "OH",
            "postal_code": "454153198",
            "telephone_number": "937-277-9371",
            "fax_number": "937-277-7734"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLACK",
        "first_name": "EDWARD",
        "middle_name": "PETERSEN",
        "name_prefix": "Dr.",
        "credential": "DO",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2012-08-16",
        "last_updated": "2023-05-03",
        "certification_date": "2023-05-03",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "OH",
            "license": "34.011463",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0122811",
            "state": "OH"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Dayton, OH

Sources for this page

Verify at the official NPI Registry.