=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073506051
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CLARK R MCKENZIE MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2005
-----------------------------------------------------
Last Update Date | 01/19/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 450 N NEW BALLAS RD STE 270 W
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63195-2632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-991-6969
-----------------------------------------------------
Fax | 314-997-6969
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 450 N NEW BALLAS RD STE 270 W
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63195-2632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-991-6969
-----------------------------------------------------
Fax | 314-997-6969
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | R4P62
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RI0011X
-----------------------------------------------------
Taxonomy Name | Interventional Cardiology Physician
-----------------------------------------------------
License Number | R4P62
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------