NPIMap

Individual provider Active NPI

Jack O. Clark, M.D.

  • Internal Medicine Physician
  • Rexburg, ID
National Provider Identifier
1902992837
Registry record updated Apr 13, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
License
M-7743 Issued in ID
Practice address
450 E Main St
Rexburg, ID 83440
Phone
(208) 359-6419
Fax
(208) 356-3111
NPI assigned
Oct 5, 2006
Last updated
Apr 13, 2020By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Apr 13, 2020

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine Physician 207R00000X M-7743 ID Primary

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

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ID
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
I20100722000929 ID Practitioner - Internal Medicine 2264564491 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
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 HospitalGroup PAC ID 8123016367, 34 clinicians
Madison Memorial HospitalGroup PAC ID 4183949522, 20 clinicians

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

National Provider Directory

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

State licenses

LicenseStateTypeSpecialty
M-7743IDMDInternal Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Madison Co Memorial Hospital Internal Medicine CurrentSince Sep 28, 2019 Accepting new patients
Madison Co Memorial Hospital Current Accepting new patients
Madison Memorial Hospital CurrentSince Mar 4, 2017 Accepting new patients
Madison Co Memorial Hospital CurrentSince Sep 28, 2019 Accepting new patients
Madison Co Memorial Hospital Current Accepting new patients
Tanabell Health Services, Inc. Past Accepting new patients

Locations

37 S 2nd E
Rexburg, ID 83440
Phone (208) 356-0234

393 E 2nd N
Rexburg, ID 83440
Phone (208) 356-5401

450 E Main St
Rexburg, ID 83440
Phone (208) 356-3691

Interoperability endpoints

  • Direct secure messaging: clarkjac@direct.madisonmemorial.org
  • FHIR API: https://fhir-myrecord.cerner.com/r4/d61ab3e4-55bb-4859-99e6-22c413b48f2a/

Ownership & related parties

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Madison Carriage Cove Short Term RehabilitationRexburg, ID, CCN 135140 Skilled nursing facility Adp of the SNF Feb 10, 2020

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Organizations & group practices 6

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 5

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": "1160006400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1586736000000",
    "number": "1902992837",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "450 E MAIN ST",
            "city": "REXBURG",
            "state": "ID",
            "postal_code": "834402048",
            "telephone_number": "208-359-6419",
            "fax_number": "208-356-3111"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "450 E MAIN ST",
            "city": "REXBURG",
            "state": "ID",
            "postal_code": "83440",
            "telephone_number": "208-359-6419",
            "fax_number": "208-356-3111"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "166 S 5th St",
            "address_2": "SUITE B",
            "address_purpose": "LOCATION",
            "city": "Montpelier",
            "state": "ID",
            "postal_code": "832541557",
            "country_code": "US",
            "telephone_number": "208-847-1110 x4975",
            "fax_number": "208-847-0228",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "CLARK",
        "first_name": "JACK",
        "middle_name": "O.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-10-05",
        "last_updated": "2020-04-13",
        "certification_date": "2020-04-13",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "ID",
            "license": "M-7743",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Rexburg, ID

Sources for this page

Verify at the official NPI Registry.