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General NPI Number Information
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NPI Number | 1730683921
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Entity Type | Individual
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Provider Name | MICHAEL BRADLEY CLARK
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Gender | Male
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Dates
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Enumeration Date | 03/21/2018
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Last Update Date | 07/13/2021
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Provider Practice Location Address
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Address Line | 555 S 70TH ST
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City | LINCOLN
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State | NE
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Zip | 68510-2494
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Country | US
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Telephone | 402-489-7181
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Fax |
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Provider Business Mailing Address
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Address Line | 265 BROOKVIEW CENTRE WAY STE 400
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City | KNOXVILLE
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State | TN
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Zip | 37919-4052
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Country | US
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Telephone | 865-985-7038
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | S6596
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 33331
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License Number State | NE
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