=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326090911
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TERENCE JOSEPH CLARKE MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2006
-----------------------------------------------------
Last Update Date | 03/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7 SOUTHWOODS BLVD STE 17
-----------------------------------------------------
City | ALBANY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12211-2564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-641-6580
-----------------------------------------------------
Fax | 518-292-6088
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 893 GROOMS RD
-----------------------------------------------------
City | REXFORD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12148-1305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-859-8271
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 222853
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------