MEDICARE: BRENDON MATTHEW CLARK

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	2255A2300X	Athletic Trainer
2	390200000X	Student in an Organized Health Care Education/Training Program		IN
3	225100000X	Physical Therapist	05015804A	IN

General Provider Information

NPI Number	:	1114483336
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENDON MATTHEW CLARK

Provider Business Mailing Address
First Line	:	8127 HEATHERY PL
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46214-2280
Country	:	US
Telephone Number	:	317-246-7549
Fax Number	:

Provider Business Practice Location Address
First Line	:	5265 E 82ND ST STE 200
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46250-1627
Country	:	US
Telephone Number	:	317-542-3723
Fax Number	:

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

Provider Enumeration Date	:	02/12/2019
Last Update Date	:	12/03/2024

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Directions to “ BRENDON MATTHEW CLARK ” Practice Location

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