Clark, Jerry Randall
Clark, Jerry Randall is an individual health care provider with primary practice located at Medical Center Blvd , Winston Salem NC 27157-0001. He recently has 2 registered licenses in different health care specialties including Allopathic & Osteopathic Physicians / Pain Medicine, Allopathic & Osteopathic Physicians / Anesthesiology. Allopathic & Osteopathic Physicians / Anesthesiology is his primary health care specialty. Clark, Jerry Randall can be contacted via phone (336) 716-2255.Contact Information
Primary practice address
Medical Center Blvd
Winston Salem NC 27157-0001
Phone: (336) 716-2255
Fax:
Website:
Health care specialties
| Specialty | Code | License # | State |
|---|---|---|---|
| Allopathic & Osteopathic Physicians / Pain Medicine | 207LP2900X | 200200013 | North Carolina |
| Allopathic & Osteopathic Physicians / Anesthesiology | 207L00000X | 200200013 | North Carolina |
Profile Details
| NPI number | 1992780860 |
|---|---|
| LBN Legal business name | Clark, Jerry Randall |
| Credentials | Doctor of Medicine (MD) |
| Entity | Individual |
| Sole proprietor 1 | No |
| Enumeration date | Dec 13th, 2005 |
| Last updated | Aug 23rd, 2017 - about 7 years ago |
1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.
Identifiers
| State | Type | Number | Issuer |
|---|---|---|---|
| All States | NPI | 1992780860 | NPPES |
| North Carolina | MEDICAID | 891302E | |
| North Carolina | Other | B4294 | |
| North Carolina | MEDICAID | Q00012 | |
| North Carolina | Other | 7543615 | |
| North Carolina | Other | 1302E | |
| North Carolina | Other | 46553 | |
| North Carolina | Other | 050086653 | |
| North Carolina | MEDICAID | 1840960000 |
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