MEDICARE: THOMAS A CLARK D.O.

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	111N00000X	Chiropractor	TC005814	MI

General Provider Information

NPI Number	:	1194796037
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS A CLARK D.O.

Provider Business Mailing Address
First Line	:	29100 GATEWAY BLVD
Second Line	:	STE 100
City	:	FLAT ROCK
State	:	MI
Zip	:	48134-2764
Country	:	US
Telephone Number	:	734-379-9200
Fax Number	:	734-379-9229

Provider Business Practice Location Address
First Line	:	29100 GATEWAY BLVD
Second Line	:	STE 100
City	:	FLAT ROCK
State	:	MI
Zip	:	48134-2764
Country	:	US
Telephone Number	:	734-379-9200
Fax Number	:	734-379-9229

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

Provider Enumeration Date	:	01/30/2006
Last Update Date	:	07/08/2007

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