Healthcare Provider Details

I. General information

NPI: 1730160896
Provider Name (Legal Business Name): SAMUEL CLARK TRASK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: S CLARK TRASK MD

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 11/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1094 RIBAUT RD
BEAUFORT SC
29902
US

IV. Provider business mailing address

1094 RIBAUT RD
BEAUFORT SC
29902-5437
US

V. Phone/Fax

Practice location:
  • Phone: 843-524-2001
  • Fax: 843-379-2004
Mailing address:
  • Phone: 843-524-2001
  • Fax: 843-379-2004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number26623
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: