Gina Clark

Haskell Regional Hospital, Inc NPI1790065399

Summary

Provider Details

NPI Number 1790065399
Provider Name Gina Clark
Credential
Specialization
Medical School Name Lincoln Memorial University Medical Department
Graduation Year 2011
Gender F
Entity Type Individual
PAC ID by PECOS 9234350166
Professional Enrollment ID I20141017002341
Enumeration Date 08/26/2011
Last Update Date 11/01/2018

Contact Details

Business Practice address 1505 E MAIN ST, Stigler,
74462-2913 Oklahoma View on Google Map
Business Practice phone 918-967-3368
Business Practice fax 918-967-4582
Mailing address PO BOX 179, Stigler,
74462-0179 Oklahoma View on Google Map
Other phone 918-967-3368
Other fax 918-967-4582
Email Address shannonfig@domain.com Reval Email Address
Incorrect information? Update the NPI Details for Gina Clark Update NPI

Payments

Total Payment Worth

$890.86
from 21 payments in the last 6 years

Total Cash or Cash Equivalent

$0.00
from 0 payments in the last 6 years

Total In-kind Items & Services

$890.86
from 21 payments in the last 6 years

Hospital Affilitation

Haskell Regional Hospital, Inc in Stigler

Stigler, Oklahoma

Saint Francis Hospital Muskogee

Eastern Oklahoma Medical Center

Mercy Hospital Fort Smith

Mcalester Regional Health Center

Education & Training

Lincoln Memorial University Medical Department

2011

Group Affiliation

Organization Name PECOS PAC ID Members
Stigler Health And Wellness Center Inc 8022061373 27
Haskell Regional Hospital Inc 1153742739 9
Newsletter for Healthcare Professionals

Provider Taxonomy Details

Provider Taxonomy 1
Taxonomy
License No.
172613 (North Carolina)
Primary Taxonomy
Taxonomy
License No.
5482 (Oklahoma)

Reference NPI Information (as per NPPES NPI Record)

Field Name Field Value
NPI 1790065399
10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider.
Entity Type Individual
Code describing the type of health care provider that is being assigned an NPI. Codes are:
  • 1 = (Person): individual human being who furnishes health care;
  • 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
Is Sole Proprietor N
Indicate whether provider is a sole proprietor.
  • A sole proprietor is the sole (the only) owner of a business that is not incorporated; that unincorporated business is a sole proprietorship.
  • In a sole proprietorship, the sole proprietor owns all of the assets of the business and is solely liable for all of the debts of the business.
  • There is no difference between a sole proprietorship and a sole proprietor; they are legally a single entity: an individual.
  • In terms of NPI assignment, a sole proprietor is an Entity type 1 (Individual) and is eligible for only one NPI (the sole proprietorship business is not eligible for its own NPI).
  • As an individual, a sole proprietorship cannot be a subpart and cannot have subparts. (See NPI Final Rule for information about subparts.)
  • A sole proprietorship may or may not have employees.
  • Often, the IRS assigns an EIN to a sole proprietorship in order to protect the sole proprietor's SSN from disclosure in claims or on W-2s. NPPES does not capture a sole proprietorship's EIN.
  • Many types of health care providers could be sole proprietorships (for example, group practices, pharmacies, home health agencies).
Provider Last Name (Legal Name) Clark
The last name of the provider (if an individual). If the provider is an individual, this is the legal name. This name must match the name on file with the Social Security Administration (SSA). In addition, the date of birth must match that on file with SSA. (First and last names are required for initial applications.) The First, Middle, Last and Credential(s) fields allow the following special characters: ampersand, apostrophe, colon, comma, forward slash, hyphen, left and right parentheses, period, pound sign, quotation mark, and semi-colon. A field cannot contain all special characters.
Provider First Name Gina
The first name of the provider, if the provider is an individual.
Provider Credential Text DO
The abbreviations for professional degrees or credentials used or held by the provider, if the provider is an individual. Examples are MD, DDS, CSW, CNA, AA, NP, RNA, or PSY. These credential designations will not be verified by NPS.
Provider First Line Business Mailing Address PO BOX 179
The first line mailing address of the provider being identified. This data element may contain the same information as ''Provider first line location address''.
Provider Business Mailing Address City Name Stigler
The City name in the mailing address of the provider being identified. This data element may contain the same information as ''Provider location address City name''.
Provider Business Mailing Address State Name Oklahoma
The State or Province name in the mailing address of the provider being identified. This data element may contain the same information as ''Provider location address State name''.
Provider Business Mailing Address Postal Code 74462-0179
The postal ZIP or zone code in the mailing address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. This data element may contain the same information as ''Provider location address postal code''.
Provider Business Mailing Address Country Code US
The country code in the mailing address of the provider being identified. This data element may contain the same information as ''Provider location address country code''.
Provider Business Mailing Address Telephone Number 918-967-3368
The telephone number associated with mailing address of the provider being identified. This data element may contain the same information as ''Provider location address telephone number''.
Provider Business Mailing Address Fax Number 918-967-4582
The fax number associated with the mailing address of the provider being identified. This data element may contain the same information as ''Provider location address fax number''.
Provider First Line Business Practice Location Address 1505 E MAIN ST
The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
Provider Business Practice Location Address City Name Stigler
The city name in the location address of the provider being identified.
Provider Business Practice Location Address State Name Oklahoma
The State or Province name in the location address of the provider being identified.
Provider Business Practice Location Address Postal Code 74462-2913
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
Provider Business Practice Location Address Country Code US
The country code in the location address of the provider being identified.
Provider Business Practice Location Address Telephone Number 918-967-3368
The telephone number associated with the location address of the provider being identified.
Provider Business Practice Location Address Fax Number 918-967-4582
The fax number associated with the location address of the provider being identified.
Provider Enumeration Date 08/26/2011
The date the provider was assigned a unique identifier (assigned an NPI).
Last Update Date 11/01/2018
The date that a record was last updated or changed.
Provider Gender Code F
The code designating the provider's gender if the provider is a person.
Provider Gender Female
The provider's gender if the provider is a person.
Healthcare Provider Taxonomy Code #1 207Q00000X
The Health Care Provider Taxonomy code is a unique alphanumeric code, ten characters in length. The code set is structured into three distinct "Levels" including Provider Type, Classification, and Area of Specialization.
Healthcare Provider Taxonomy 1 Family Medicine is the medical specialty which is concerned with the total health care of the individual and the family. It is the specialty in breadth which integrates the biological, clinical, and behavioral sciences. The scope of family medicine is not limited by age, sex, organ system, or disease entity.
Healthcare Provider Taxonomy #1
Provider License Number 1 172613
Certain taxonomy selections will require you to enter your license number and the state where the license was issued. Select Foreign Country in the state drop down box if the license was issued outside of United States. The License Number field allows the following special characters: ampersand, apostrophe, colon, comma, forward slash, hyphen, left and right parentheses, period, pound sign, quotation mark, and semi-colon. A field cannot contain all special characters. DO NOT report the Social Security Number (SSN), IRS Individual Taxpayer Identification Number (ITIN) in this section.
Provider License Number State Code 1 NC
Provider License Number State Code #1
Healthcare Provider Primary Taxonomy Switch 1 N
Primary Taxonomy:
  • X - The primary taxonomy switch is Not Answered;
  • Y - The taxonomy is the primary taxonomy (there can be only one per NPI record);
  • N - The taxonomy is not the primary taxonomy.
Healthcare Provider Taxonomy Code #2 207QS0010X
The Health Care Provider Taxonomy code is a unique alphanumeric code, ten characters in length. The code set is structured into three distinct "Levels" including Provider Type, Classification, and Area of Specialization.
Healthcare Provider Taxonomy 2 A family medicine physician that is trained to be responsible for continuous care in the field of sports medicine, not only for the enhancement of health and fitness, but also for the prevention of injury and illness. A sports medicine physician must have knowledge and experience in the promotion of wellness and the prevention of injury. Knowledge about special areas of medicine such as exercise physiology, biomechanics, nutrition, psychology, physical rehabilitation, epidemiology, physical evaluation, injuries (treatment and prevention and referral practice) and the role of exercise in promoting a healthy lifestyle are essential to the practice of sports medicine. The sports medicine physician requires special education to provide the knowledge to improve the health care of the individual engaged in physical exercise (sports) whether as an individual or in team participation.
Healthcare Provider Taxonomy #2
Provider License Number 2 5482
Certain taxonomy selections will require you to enter your license number and the state where the license was issued. Select Foreign Country in the state drop down box if the license was issued outside of United States. The License Number field allows the following special characters: ampersand, apostrophe, colon, comma, forward slash, hyphen, left and right parentheses, period, pound sign, quotation mark, and semi-colon. A field cannot contain all special characters. DO NOT report the Social Security Number (SSN), IRS Individual Taxpayer Identification Number (ITIN) in this section.
Provider License Number State Code 2 OK
Provider License Number State Code #2
Healthcare Provider Primary Taxonomy Switch 2 Y
Primary Taxonomy:
  • X - The primary taxonomy switch is Not Answered;
  • Y - The taxonomy is the primary taxonomy (there can be only one per NPI record);
  • N - The taxonomy is not the primary taxonomy.