Healthcare Provider Details

I. General information

NPI: 1669765756
Provider Name (Legal Business Name): TIMOTHY ADAM CLARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2011
Last Update Date: 11/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 SHORTER AVE NW SUITE 201
ROME GA
30165-4290
US

IV. Provider business mailing address

304 SHORTER AVE NW SUITE 201
ROME GA
30165-4290
US

V. Phone/Fax

Practice location:
  • Phone: 706-509-3334
  • Fax: 706-509-4272
Mailing address:
  • Phone: 706-509-3334
  • Fax: 706-509-4272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number69566
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number69566
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: