Basic Information
| Provider Information | |||||||||
| NPI: | 1649680406 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | AMOS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3841 GREEN HILLS VILLAGE DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372152691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6159362000 | ||||||||
| FaxNumber: | 6159360605 | ||||||||
| Practice Location | |||||||||
| Address1: | VANDERBILT UNIVERSITY DEPT OF MEDICINE | ||||||||
| Address2: | D-3100, MEDICAL CENTER NORTH | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153220417 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2014 | ||||||||
| LastUpdateDate: | 03/26/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 56206 | TN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207R00000X | 56206 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | Q031277 | 05 | TN | MEDICAID |