MEDICARE: ELEANOR A. CLARK, MD,PC

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	207VG0400X	Gynecology Physician	16389	AZ

General Provider Information

NPI Number	:	1871754184
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELEANOR A. CLARK, MD,PC

Provider Business Mailing Address
First Line	:	1821 N TREKELL RD
Second Line	:	SUITE 1
City	:	CASA GRANDE
State	:	AZ
Zip	:	85122-1705
Country	:	US
Telephone Number	:	520-836-1760
Fax Number	:	520-836-3033

Provider Business Practice Location Address
First Line	:	1821 N TREKELL RD
Second Line	:	SUITE 1
City	:	CASA GRANDE
State	:	AZ
Zip	:	85122-1705
Country	:	US
Telephone Number	:	520-836-1760
Fax Number	:	520-836-3033

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ELEANOR A. CLARK
Credential	:	MD
Telephone Number	:	520-836-1760

Provider Enumeration Date	:	06/19/2008
Last Update Date	:	09/30/2011

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