Individual
DR. CLARK R MCKENZIE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
450 N NEW BALLAS RD, STE 270 W, SAINT LOUIS, MO 63195-2632
(314) 991-6969
(314) 997-6969
Mailing address
450 N NEW BALLAS RD, STE 270 W, SAINT LOUIS, MO 63195-2632
(314) 991-6969
(314) 997-6969
Taxonomy
Speciality
Code
Description
License number
State
207RC0000X
Cardiovascular Disease Physician
R4P62
MO
207RI0011X
Interventional Cardiology Physician
Primary
R4P62
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000047049
MCARE CCL GROUP NUMBER
MO
01
—
004013185
MEDICARE PROV ID AREA 99
MO
01
—
006012762
MEDICARE PROVIDER ID
—
01
—
110171721
RR MEDICARE NUMBER
MO
01
—
1124011010
HHC CATH GROUP NPI
MO
01
—
1801889795
STL GROUP NPI
MO
01
—
1881863009
FARM GROUP NPI
MO
01
—
CD6536
RR GROUP 01
MO
01
—
CI7050
RR GROUP 99
MO
01
—
MA1080
CCL GROUP NUMBER
MO
01
—
MA1080001
CCL INDIVDUAL PROV NUMBER
MO
01
—
P00275849
RR CCL GROUP
MO
Enumeration date
08/25/2005
Last updated
01/19/2016
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