=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740068683
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALEXANDER CHASE CLARK PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2023
-----------------------------------------------------
Last Update Date | 09/21/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12680 PERRY HWY STE 201
-----------------------------------------------------
City | WEXFORD
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15090-8887
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-714-5189
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12680 PERRY HWY STE 201
-----------------------------------------------------
City | WEXFORD
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15090-8887
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-720-4600
-----------------------------------------------------
Fax | 724-720-4601
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XS0117X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery of the Spine Physician
-----------------------------------------------------
License Number | MA064980
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------