Healthcare Provider Details

I. General information

NPI: 1487664835
Provider Name (Legal Business Name): KEVIN M CLARKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 VIP WAY
FAIRMONT WV
26554
US

IV. Provider business mailing address

200 ROUTE 98 W ST SUITE 107
NUTTER FORT WV
26301-4385
US

V. Phone/Fax

Practice location:
  • Phone: 304-366-6200
  • Fax: 304-366-4927
Mailing address:
  • Phone: 304-623-5711
  • Fax: 304-624-0461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number15547
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number15547
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: