MEDICARE: DR. HEATHER MICHELLE CLARK 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	207P00000X	Emergency Medicine Physician	01069280A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01069280A	OTHER	IN	IN PHYSICIAN LICENSE

General Provider Information

NPI Number	:	1558523795
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HEATHER MICHELLE CLARK MD

Provider Business Mailing Address
First Line	:	608 UNION CHAPEL RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-9357
Country	:	US
Telephone Number	:	260-482-4440
Fax Number	:	260-482-4442

Provider Business Practice Location Address
First Line	:	1316 E 7TH ST
Second Line	:
City	:	AUBURN
State	:	IN
Zip	:	46706-2538
Country	:	US
Telephone Number	:	260-373-4000
Fax Number	:	260-482-4442

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

Provider Enumeration Date	:	06/30/2008
Last Update Date	:	05/07/2024

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