Healthcare Provider Details

I. General information

NPI: 1700183993
Provider Name (Legal Business Name): MICHAEL BRADY CLARK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2011
Last Update Date: 06/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 MCKEAN RD
SPRING HOUSE PA
19477
US

IV. Provider business mailing address

1400 MCKEAN RD PO BOX 776
SPRING HOUSE PA
19477
US

V. Phone/Fax

Practice location:
  • Phone: 215-793-7131
  • Fax:
Mailing address:
  • Phone: 215-793-7131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number0101056149
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number055114
License Number StateGA

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: