Basic Information
| Provider Information | |||||||||
| NPI: | 1366804536 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARKE | ||||||||
| FirstName: | BRIAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 635283 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452635283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593445555 | ||||||||
| FaxNumber: | 8593445552 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 MEDICAL VILLAGE DR STE 132 | ||||||||
| Address2: | |||||||||
| City: | EDGEWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410175406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8595785880 | ||||||||
| FaxNumber: | 8595785881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2016 | ||||||||
| LastUpdateDate: | 10/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2086S0102X | 57309 | KY | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care |
ID Information
| ID | Type | State | Issuer | Description | 57309 | 01 | KY | MEDICAL LICENSE | OTHER | FC1971375 | 01 | DEA LICENSE | OTHER | 21718 | 01 | HI | MEDICAL LICENSE | OTHER |