MEDICARE: DR. RANDALL NORTON CLARK MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	RC050413	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	RC050413	OTHER	MI	STATE LICENSE NUMBER
3	080D14848	OTHER	MI	BCBS PROVIDER ID

General Provider Information

NPI Number	:	1063573319
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RANDALL NORTON CLARK MD

Provider Business Mailing Address
First Line	:	3980 CHICAGO DR SW STE 200
Second Line	:
City	:	GRANDVILLE
State	:	MI
Zip	:	49418-1392
Country	:	US
Telephone Number	:	616-381-5181
Fax Number	:	616-381-5178

Provider Business Practice Location Address
First Line	:	3980 CHICAGO DR SW STE 200
Second Line	:
City	:	GRANDVILLE
State	:	MI
Zip	:	49418-1392
Country	:	US
Telephone Number	:	616-381-5181
Fax Number	:	616-381-5178

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/12/2006
Last Update Date	:	07/18/2025

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