MEDICARE: DR. KATHY S 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	2085R0202X	Diagnostic Radiology Physician	01036050A	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	300128808	OTHER	IN	RR MEDICARE-351158723

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000214716	OTHER	IN	ANTHEM-351158723
3	000000492338	OTHER	IN	ANTHEM 203778927
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	085331	OTHER	IN	HEALTH ALLIANCE-351158723
6	Q0085630	OTHER	IN	CMOSHO351158723-352047427
7	011838	OTHER	IN	SIHO-351158723

General Provider Information

NPI Number	:	1952304701
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KATHY S CLARK MD

Provider Business Mailing Address
First Line	:	5901 TECHNOLOGY CENTER DR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46278-6013
Country	:	US
Telephone Number	:	317-328-5050
Fax Number	:	317-328-5053

Provider Business Practice Location Address
First Line	:	5901 TECHNOLOGY CENTER DR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46278-6013
Country	:	US
Telephone Number	:	317-328-5050
Fax Number	:	317-715-9965

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

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	10/03/2016

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Directions to “ DR. KATHY S CLARK MD” Practice Location

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