Basic Information
| Provider Information | |||||||||
| NPI: | 1730115676 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | LUCAS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 INDEPENDENCE PT | ||||||||
| Address2: | SUITE 212 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296154545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8647976044 | ||||||||
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| Practice Location | |||||||||
| Address1: | 727 SE MAIN ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SIMPSONVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296813247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644546520 | ||||||||
| FaxNumber: | 8644546525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 05/17/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 21043 | SC | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 57-1004971003 | 01 | SC | BCBS OF SC | OTHER | 7742353 | 01 | SC | AETNA | OTHER | 210435 | 05 | SC | MEDICAID |