Jack O. Clark, M.D.
Individual provider Active NPI Internal Medicine Physician · Rexburg, ID
NPI 1902992837 · NPPES record last updated Apr 13, 2020
Key facts
- NPI
- 1902992837
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Internal Medicine Physician 207R00000X
- License
- M-7743 (ID)
- Practice address
- 450 E Main St
Rexburg, ID 83440 - Phone
- (208) 359-6419
- Fax
- (208) 356-3111
- NPI assigned
- Oct 5, 2006
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 7
Hospital & facility affiliations 5
Owned or controlled facilities with NPI records 1
Medicare Care Compare profile
- Specialty
- Internal Medicine
- Education
- Pennsylvania State University College of Medicine, 1999
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Group practices
- Madison Co Memorial Hospital
Madison Memorial Hospital
Practice addresses (Care Compare)
37 S 2ND
Rexburg, ID 83440-1906
Phone (208) 356-0234
450 E Main St
Reburg, ID 83440-2048
Phone (208) 359-6516
Hospital & facility affiliations
- Madison Memorial Hospital
- Mountain View Hospital
- Eastern Idaho Regional Medical Center
- Madison Carriage Cove Short Stay Rehabilitation
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in ID
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: Yes
All facility ownership & control disclosures 1
| Facility | Type | Role | Since |
|---|---|---|---|
| Madison Carriage Cove Short Term Rehabilitation |
Skilled nursing facility | Adp of the SNF | Feb 10, 2020 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20100722000929 | ID | Practitioner - Internal Medicine | 2264564491 | Reassigns benefits to 2 organizations |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| M-7743 | ID | MD | Internal Medicine Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Madison Co Memorial Hospital | Current | Accepting new patients | |
| Madison Co Memorial Hospital | Current | Accepting new patients | |
| Madison Co Memorial Hospital | Current |
Accepting new patients | |
| Madison Memorial Hospital | Current |
Accepting new patients | |
| Madison Co Memorial Hospital | Internal Medicine | Current |
Accepting new patients |
| Tanabell Health Services, Inc. | Past | Accepting new patients |
Locations
450 E Main St
Rexburg, ID 83440
Phone (208) 356-3691
37 S 2nd E
Rexburg, ID 83440
Phone (208) 356-0234
393 E 2nd N
Rexburg, ID 83440
Phone (208) 356-5401
Interoperability endpoints
- clarkjac@direct.madisonmemorial.org
- https://fhir-myrecord.cerner.com/r4/d61ab3e4-55bb-4859-99e6-22c413b48f2a/
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Internal Medicine Physician | 207R00000X | M-7743 | ID | Yes |
Addresses
Primary practice location
450 E Main St
Rexburg, ID 83440
Mailing address
450 E Main St
Rexburg, ID 83440-2048
Phone (208) 359-6419
Other practice location 1
166 S 5th St
Suite B
Montpelier, ID 83254-1557
Phone (208) 847-1110 ext. 4975
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 10018055 | Other | ID | REGENCE BCBS IDAHO |
| 114780300 | Medicaid | WY | |
| 80633500 | Medicaid | ID | |
| 58289 | Other | ID | BLUE CROSS IDAHO |
| 805499200 | Medicaid | ID |
Other providers in Rexburg, ID
- Jonathan Chidester
- Child and Family Resource
- Brian Wade Christensen
- Louie Cibrian
- Graciela Maria Clark
- Kimberly Clark
- Kohlee Clark
- Susan B Clark
- Janell Clement
- Zackery J Cleverley
All providers in Rexburg, ID · Internal Medicine Physician in Idaho
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 13, 2020. 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.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- 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.