MEDICARE: MICHAEL CLARK

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	2081S0010X	Sports Medicine (Physical Medicine & Rehabilitation) Physician	1624	FL

General Provider Information

NPI Number	:	1942715255
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL CLARK

Provider Business Mailing Address
First Line	:	3192 MERRICK TERRACE
Second Line	:
City	:	MARGATE
State	:	FL
Zip	:	33063
Country	:	US
Telephone Number	:	954-812-5661
Fax Number	:

Provider Business Practice Location Address
First Line	:	10600 RIVERSIDE DRIVE
Second Line	:
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33071-3307
Country	:	US
Telephone Number	:	954-812-5661
Fax Number	:	954-812-5661

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

Provider Enumeration Date	:	12/08/2017
Last Update Date	:	12/08/2017

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Directions to “ MICHAEL CLARK ” Practice Location

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