Provider Demographics
NPI:1043362320
Name:THOMAS-CLARK, G RENEE (DO)
Entity type:Individual
Prefix:
First Name:G
Middle Name:RENEE
Last Name:THOMAS-CLARK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 LECOM PL
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-2571
Mailing Address - Country:US
Mailing Address - Phone:814-868-2529
Mailing Address - Fax:814-868-2522
Practice Address - Street 1:4740 PEACH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509-2008
Practice Address - Country:US
Practice Address - Phone:814-454-3174
Practice Address - Fax:814-616-8002
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS0153382084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
2758232555OtherBLUE CROSS
MI4120606Medicaid
MI4120606Medicaid