MEDICARE: CLARK D PHELPS III 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	208600000X	Surgery Physician	LL82868	SC

General Provider Information

NPI Number	:	1730749151
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLARK D PHELPS III MD

Provider Business Mailing Address
First Line	:	701 GROVE RD FL 3
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29605-4295
Country	:	US
Telephone Number	:	864-455-1435
Fax Number	:	864-455-1320

Provider Business Practice Location Address
First Line	:	701 GROVE RD FL 3
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29605-4295
Country	:	US
Telephone Number	:	864-455-1435
Fax Number	:	864-455-1320

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

Provider Enumeration Date	:	06/18/2019
Last Update Date	:	06/18/2019

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