Provider Demographics
NPI:1871550244
Name:CLARK, JOHN ROSS
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ROSS
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:MASS GENERAL PHYSICIANS ORGANIZATION INC
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-724-4000
Mailing Address - Fax:617-643-1915
Practice Address - Street 1:55 FRUIT STREET
Practice Address - Street 2:YAW 7B MASS GENERAL HOSPITAL
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2696
Practice Address - Country:US
Practice Address - Phone:617-724-4000
Practice Address - Fax:617-643-1915
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA49154207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6194613Medicaid
J02760OtherBLUE CROSS BLUE SHIELD
MA6194613Medicaid
J02760OtherBLUE CROSS BLUE SHIELD