Healthcare Provider Details

I. General information

NPI: 1679017552
Provider Name (Legal Business Name): NORTON CLARK PHYSICIAN PRACTICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2016
Last Update Date: 11/07/2023
Certification Date: 11/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2205 GREENTREE N
CLARKSVILLE IN
47129-8957
US

IV. Provider business mailing address

4803 OLYMPIA PARK PLZ STE 1100
LOUISVILLE KY
40241-3009
US

V. Phone/Fax

Practice location:
  • Phone: 812-283-4441
  • Fax: 812-288-2605
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28168470A
License Number StateIN

VIII. Authorized Official

Name: SHELLEY GAST
Title or Position: VP MANAGED CARE
Credential:
Phone: 502-559-9409