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General NPI Number Information
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NPI Number | 1053387936
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Entity Type | Individual
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Provider Name | MICHAEL E CLARK MD
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Gender | Male
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Dates
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Enumeration Date | 02/28/2006
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Last Update Date | 10/16/2012
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Provider Practice Location Address
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Address Line | 4 SHERIDAN DRIVE
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City | FAIRFIELD
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State | ME
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Zip | 04937
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Country | US
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Telephone | 207-861-5000
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Fax | 207-861-5001
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Provider Business Mailing Address
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Address Line | 4 SHERIDAN RD
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City | FAIRFIELD
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State | ME
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Zip | 04937-3314
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Country | US
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Telephone | 207-861-5000
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Fax | 207-861-5001
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 013687
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License Number State | ME
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