MEDICARE: DR. CLARK R MCKENZIE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RC0000X	Cardiovascular Disease Physician	R4P62	MO
2	207RI0011X	Interventional Cardiology Physician	R4P62	MO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	004013185	OTHER	MO	MEDICARE PROV ID AREA 99
5	006012762	OTHER		MEDICARE PROVIDER ID
6	110171721	OTHER	MO	RR MEDICARE NUMBER

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	1124011010	OTHER	MO	HHC CATH GROUP NPI
3	1881863009	OTHER	MO	FARM GROUP NPI
4	P00275849	OTHER	MO	RR CCL GROUP
7	000047049	OTHER	MO	MCARE CCL GROUP NUMBER
8	CI7050	OTHER	MO	RR GROUP 99
9	MA1080	OTHER	MO	CCL GROUP NUMBER
10	1801889795	OTHER	MO	STL GROUP NPI
11	MA1080001	OTHER	MO	CCL INDIVDUAL PROV NUMBER
12	CD6536	OTHER	MO	RR GROUP 01

General Provider Information

NPI Number	:	1073506051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CLARK R MCKENZIE MD

Provider Business Mailing Address
First Line	:	450 N NEW BALLAS RD
Second Line	:	STE 270 W
City	:	SAINT LOUIS
State	:	MO
Zip	:	63195-2632
Country	:	US
Telephone Number	:	314-991-6969
Fax Number	:	314-997-6969

Provider Business Practice Location Address
First Line	:	450 N NEW BALLAS RD
Second Line	:	STE 270 W
City	:	SAINT LOUIS
State	:	MO
Zip	:	63195-2632
Country	:	US
Telephone Number	:	314-991-6969
Fax Number	:	314-997-6969

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/25/2005
Last Update Date	:	01/19/2016

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