Basic Information
| Provider Information | |||||||||
| NPI: | 1073695045 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | KELLEY | ||||||||
| MiddleName: | D. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3421 CONCORD RD | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174029001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178511405 | ||||||||
| FaxNumber: | 7178516969 | ||||||||
| Practice Location | |||||||||
| Address1: | 35 MONUMENT RD STE 202 | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174035074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178512722 | ||||||||
| FaxNumber: | 7178513127 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 04/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VM0101X | 40584 | TN | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine | 207VM0101X | 0101259164 | VA | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine | 207VM0101X | 30720 | KY | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine | 207VM0101X | MD431748 | PA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64307200 | 05 | KY | MEDICAID |