Provider Demographics
NPI:1912946732
Name:CLARK, ELOISE MARIE (MD)
Entity type:Individual
Prefix:
First Name:ELOISE MARIE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 HIGHWAY 59 S
Mailing Address - Street 2:
Mailing Address - City:THIEF RIVER FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56701-4331
Mailing Address - Country:US
Mailing Address - Phone:218-681-4747
Mailing Address - Fax:218-683-2595
Practice Address - Street 1:1720 HIGHWAY 59 S
Practice Address - Street 2:
Practice Address - City:THIEF RIVER FALLS
Practice Address - State:MN
Practice Address - Zip Code:56701-4331
Practice Address - Country:US
Practice Address - Phone:218-681-4747
Practice Address - Fax:218-683-2595
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN47488207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FM25707OtherNDBS #
MN058453300Medicaid
MN13554Medicaid
FM43201OtherLHS/BANNERHEALTH #
MN2364648OtherAMERICA'S PPO/ARAZ #
MNHP53190OtherHEALTHPARTNERS #
MN137002OtherUCARE #
MNDA9021044062OtherPREFERRED ONE #
MN0704419OtherMEDICA #
MN300S9CLOtherMNBS #
FM43201OtherLHS/BANNERHEALTH #
MNH30553Medicare UPIN
MN160002786Medicare PIN