Provider Demographics
NPI:1023174273
Name:EDITH CLARK DPM PLLC
Entity type:Organization
Organization Name:EDITH CLARK DPM PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:EDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:989-386-9721
Mailing Address - Street 1:4310 LEONARD ST NW
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WALKER
Mailing Address - State:MI
Mailing Address - Zip Code:49534-8447
Mailing Address - Country:US
Mailing Address - Phone:616-453-6329
Mailing Address - Fax:616-453-1725
Practice Address - Street 1:125 DWYER ST
Practice Address - Street 2:
Practice Address - City:CLARE
Practice Address - State:MI
Practice Address - Zip Code:48617-1002
Practice Address - Country:US
Practice Address - Phone:989-386-9721
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIEC001742213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4613888Medicaid
MI0N91350Medicare ID - Type UnspecifiedMEDICARE
MI5809480001Medicare NSC
MI4613888Medicaid