Healthcare Provider Details

I. General information

NPI: 1073506051
Provider Name (Legal Business Name): CLARK R MCKENZIE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 01/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 N NEW BALLAS RD STE 270 W
SAINT LOUIS MO
63195-2632
US

IV. Provider business mailing address

450 N NEW BALLAS RD STE 270 W
SAINT LOUIS MO
63195-2632
US

V. Phone/Fax

Practice location:
  • Phone: 314-991-6969
  • Fax: 314-997-6969
Mailing address:
  • Phone: 314-991-6969
  • Fax: 314-997-6969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberR4P62
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberR4P62
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: