Healthcare Provider Details

I. General information

NPI: 1245278555
Provider Name (Legal Business Name): MARK REID CLUTTER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 11/05/2024
Certification Date:
Deactivation Date: 10/23/2024
Reactivation Date: 11/05/2024

III. Provider practice location address

3700 KOLBE RD
LORAIN OH
44053-1611
US

IV. Provider business mailing address

200 CORPORATE BLVD
LAFAYETTE LA
70508-3870
US

V. Phone/Fax

Practice location:
  • Phone: 440-960-3000
  • Fax:
Mailing address:
  • Phone: 800-893-9698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50001285
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number50.001285
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: