Healthcare Provider Details

I. General information

NPI: 1760460802
Provider Name (Legal Business Name): MARY HOLLAND HOBACK CLARK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: HOLLY HOBACK CLARK MD

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BARRON DR
INSTITUTE WV
25112-1004
US

IV. Provider business mailing address

PO BOX 1004 BARRON DR
INSTITUTE WV
25112-1004
US

V. Phone/Fax

Practice location:
  • Phone: 304-766-4855
  • Fax: 304-766-4954
Mailing address:
  • Phone: 304-766-4855
  • Fax: 304-766-4954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number10892
License Number StateWV

VII. Legacy identifiers

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

# 1
Identifier0116792000
Identifier TypeMEDICAID
Identifier StateWV
Identifier Issuer
# 2
Identifier10892
Identifier TypeOTHER
Identifier StateWV
Identifier IssuerWV BD OF MEDECINE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: