=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215977889
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GEORGE THOMAS CLARK III MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2006
-----------------------------------------------------
Last Update Date | 02/01/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3713 BENSON DRIVE, SUITE 201 CAROLINA VASCULAR SURGERY & DIAGNOSTICS, PA
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27609-7372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-235-3400
-----------------------------------------------------
Fax | 919-235-3401
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3713 BENSON DRIVE SUITE 201
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27609-7372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-235-3400
-----------------------------------------------------
Fax | 919-235-3401
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 32073
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------