Healthcare Provider Details

I. General information

NPI: 1336436054
Provider Name (Legal Business Name): CHRISTOPHER D CLARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2011
Last Update Date: 01/22/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MONROE AVE NW
GRAND RAPIDS MI
49503-1455
US

IV. Provider business mailing address

4100 EMBASSY DR SE STE 400
GRAND RAPIDS MI
49546-2416
US

V. Phone/Fax

Practice location:
  • Phone: 616-732-6200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number4301098458
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4301098458
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: