Physician Compare National (NPI:1548495336)

HEALTHCARE PROVIDER: SHANE CHAMBERLAIN CLARK M.D.

Physician Compare National contains general information about individual eligible professionals (EPs) such as demographic information and Medicare quality program participation.

Individual Professional Information
NPI	1548495336
	Unique healthcare provider (clinician) ID assigned by NPPES
PECOS UID	6800036963
	Unique individual clinician ID assigned by PECOS
Professional Enrollment ID	I20130712000591
	Unique ID for the individual professional enrollment that is the source for the data in the observation
Provider Last Name	CLARK
	Individual professional last name
Provider First Name	SHANE
	Individual professional first name
Provider Gender	M
	The provider's gender if the provider is a person.

Medical School Information
Medical School Name	OHIO STATE UNIVERSITY COLLEGE OF MEDICINE
	Individual professional's medical school
Graduation Year	2009
	Individual professional's medical school graduation year
Primary Specialty	DERMATOLOGY
	Primary medical specialty reported by the individual professional in the selected enrollment

Practice Information
Organization Legal Name	DERMATOLOGISTS OF SOUTHWESTERN OHIO, LLC
	Legal name of the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
Group Practice PAC ID	7113973041
	Unique Group Practice ID assigned by PECOS to the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
Number of Group Practice members	71
	Total number of individual professionals affiliated with the Group Practice based on Group Practice PAC ID
Line 1 Street Address	324 E MILLTOWN RD
	Group Practice or individual's line 1 address
Line 2 Street Address	SUITE C
	Group Practice or individual's line 2 address
City	WOOSTER
	Group Practice or individual's city
State	OH
	Group Practice or individual's state
Zip Code	446912269
	Group Practice or individual's zip code (9 digits when available)
Phone Number	3303451540
	Phone number is listed only when there is a single phone number available for the practice location address

Hospital(s) Affiliation Information
Hospital Affiliation CCN 1	360036
	Medicare CCN of hospital where individual professional provides service 1
Hospital Affiliation LBN 1	WOOSTER COMMUNITY HOSPITAL
	Legal business name of hospital where individual professional provides service 1
Hospital Affiliation CCN 2	361323
	Medicare CCN of hospital where individual professional provides service 2
Hospital Affiliation LBN 2	AULTMAN ORRVILLE HOSPITAL
	Legal business name of hospital where individual professional provides service 2
Professional Accepts Medicare Assignment	Y