Provider Demographics
NPI:1053387936
Name:CLARK, MICHAEL E (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:E
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:ME
Mailing Address - Zip Code:04937-3314
Mailing Address - Country:US
Mailing Address - Phone:207-861-5000
Mailing Address - Fax:207-861-5001
Practice Address - Street 1:4 SHERIDAN DRIVE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:ME
Practice Address - Zip Code:04937
Practice Address - Country:US
Practice Address - Phone:207-861-5000
Practice Address - Fax:207-861-5001
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME013687207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1053387936Medicaid
ME272100099Medicaid
ME080104570Medicare PIN
MEMM5196Medicare PIN
MEF2445Medicare UPIN
ME1053387936Medicaid