Basic Information
| Provider Information | |||||||||
| NPI: | 1699750679 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | HOLLINS | ||||||||
| MiddleName: | PEEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 344 | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271020344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162255 | ||||||||
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| Practice Location | |||||||||
| Address1: | 101 MANNING DR | ||||||||
| Address2: | |||||||||
| City: | CHAPEL HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275144220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9849741000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2005 | ||||||||
| LastUpdateDate: | 02/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | 200000751 | NC | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085R0204X | 200000751 | NC | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0202X | 200000751 | NC | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 70404 | 01 | NC | PARTNERS | OTHER | 7214821 | 05 | VA | MEDICAID | Q00754 | 05 | SC | MEDICAID | 127R2 | 01 | NC | BCBS | OTHER | 7557322 | 01 | NC | AETNA | OTHER | 2002481000 | 05 | WV | MEDICAID | 89127R2 | 05 | NC | MEDICAID | A2500 | 01 | NC | MEDCOST | OTHER |