=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194814582
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN T CLARKE NP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10701 EAST BLVD
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-791-3800
-----------------------------------------------------
Fax | 216-707-5987
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 64 DIVISION ST
-----------------------------------------------------
City | HUDSON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44236-3050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-528-0558
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | RN262731
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------