MEDICARE: MICHAEL J CLARK PT

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	225100000X	Physical Therapist	2569	OR
2	225100000X	Physical Therapist	PT00005772	WA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	650011919	OTHER	WA	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	0766690001	OTHER	WA	CIGNA GOVERNMENT SERVICES
3	108672	OTHER	WA	LABOR & INDUSTRIES PROVID
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	CL5823	OTHER	WA	REGENCE BC/BS

General Provider Information

NPI Number	:	1306849955
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL J CLARK PT

Provider Business Mailing Address
First Line	:	275 W TIETAN ST
Second Line	:
City	:	WALLA WALLA
State	:	WA
Zip	:	99362-4363
Country	:	US
Telephone Number	:	509-522-0114
Fax Number	:	509-522-9868

Provider Business Practice Location Address
First Line	:	275 W TIETAN ST
Second Line	:
City	:	WALLA WALLA
State	:	WA
Zip	:	99362-4363
Country	:	US
Telephone Number	:	509-522-0114
Fax Number	:	509-522-9868

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

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	09/15/2022

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Directions to “ MICHAEL J CLARK PT” Practice Location

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