Provider Demographics
NPI:1063475432
Name:CLARKE, KEVIN (PA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:CLARKE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 HARGER RD STE 408
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1818
Mailing Address - Country:US
Mailing Address - Phone:630-581-6522
Mailing Address - Fax:
Practice Address - Street 1:333 MADISON ST
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-8200
Practice Address - Country:US
Practice Address - Phone:815-725-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001326363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK25116Medicare ID - Type Unspecified
ILS96006Medicare UPIN