Provider Demographics
NPI:1194146845
Name:BISHOP, CLARK II (4704202764)
Entity type:Individual
Prefix:MR
First Name:CLARK
Middle Name:
Last Name:BISHOP
Suffix:II
Gender:M
Credentials:4704202764
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26766 STANFORD ST
Mailing Address - Street 2:
Mailing Address - City:INKSTER
Mailing Address - State:MI
Mailing Address - Zip Code:48141-3135
Mailing Address - Country:US
Mailing Address - Phone:313-283-7001
Mailing Address - Fax:
Practice Address - Street 1:1700 WATERMAN ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48209-2022
Practice Address - Country:US
Practice Address - Phone:313-841-8900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-26
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704202764163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse