Healthcare Provider Details

I. General information

NPI: 1366804536
Provider Name (Legal Business Name): BRIAN CLARKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2016
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 MEDICAL VILLAGE DR
EDGEWOOD KY
41017-5401
US

IV. Provider business mailing address

PO BOX 635283
CINCINNATI OH
45263-5283
US

V. Phone/Fax

Practice location:
  • Phone: 859-578-5880
  • Fax: 859-578-5881
Mailing address:
  • Phone: 859-578-5880
  • Fax: 859-578-5881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number57309
License Number StateKY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier21718
Identifier TypeOTHER
Identifier StateHI
Identifier IssuerMEDICAL LICENSE
# 2
Identifier57309
Identifier TypeOTHER
Identifier StateKY
Identifier IssuerMEDICAL LICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: