Organization
ROBERT B CLARK JR MD LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
PRISCILLA E EDGE (CREDENTIALING)
(912) 537-8691
Entity
Organization
Contact information
Practice address
1811 MANNING DRIVE, VIDALIA, GA 30474
(912) 537-6634
(912) 537-1909
Mailing address
1811 MANNING DRIVE, VIDALIA, GA 30474
(912) 537-6634
(912) 537-1909
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
020521
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000177713D
—
GA
01
—
1144289349
PERSONAL NPI NUMBER 1144289349
GU
01
—
449866340
MEDICAID REFERRAL
GA
01
—
GRP7739
MEDICARE GROUP NUMBER
GA
Enumeration date
07/05/2006
Last updated
03/27/2013
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