=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417680612
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLARK PALLIATIVE MEDICINE GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2022
-----------------------------------------------------
Last Update Date | 02/05/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2501 PARKERS LN FL 4
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22306-3209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-664-7000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3575 BRIDGE RD STE 8
-----------------------------------------------------
City | SUFFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23435-1800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-582-1629
-----------------------------------------------------
Fax | 757-819-4995
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. VICTOR PIERRE CLARK
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 757-582-1629
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RH0002X
-----------------------------------------------------
Taxonomy Name | Hospice and Palliative Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------