MEDICARE: BEVERLY MARIE 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	207Q00000X	Family Medicine Physician	04-34503	KS
2	207Q00000X	Family Medicine Physician	94-07126	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1649404625
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BEVERLY MARIE CLARK MD

Provider Business Mailing Address
First Line	:	309 SANDERS ST
Second Line	:
City	:	BURLINGTON
State	:	KS
Zip	:	66839-2616
Country	:	US
Telephone Number	:	620-364-5395
Fax Number	:	620-364-8719

Provider Business Practice Location Address
First Line	:	1004 E. MADISON ST
Second Line	:
City	:	YATES CENTER
State	:	KS
Zip	:	66783-1314
Country	:	US
Telephone Number	:	620-625-2312
Fax Number	:	620-625-3560

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

Provider Enumeration Date	:	05/06/2009
Last Update Date	:	04/07/2016

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Directions to “ BEVERLY MARIE CLARK MD” Practice Location

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