MEDICARE: GERALD H. CLARK M.D.

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	2080A0000X	Pediatric Adolescent Medicine Physician	026083	GA

General Provider Information

NPI Number	:	1386640241
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GERALD H. CLARK M.D.

Provider Business Mailing Address
First Line	:	1285 HEMBREE RD
Second Line	:	STE 100
City	:	ROSWELL
State	:	GA
Zip	:	30076-5715
Country	:	US
Telephone Number	:	770-442-1050
Fax Number	:	770-442-9618

Provider Business Practice Location Address
First Line	:	1285 HEMBREE RD
Second Line	:	STE 100
City	:	ROSWELL
State	:	GA
Zip	:	30076-5715
Country	:	US
Telephone Number	:	770-442-1050
Fax Number	:	770-442-9618

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

Provider Enumeration Date	:	06/24/2005
Last Update Date	:	07/09/2007

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