Provider Demographics
NPI:1346238177
Name:ROSE, CLEMENT S (MD)
Entity Type:Individual
Prefix:
First Name:CLEMENT
Middle Name:S
Last Name:ROSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:4646 N MARINE DR STE A6100
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5759
Mailing Address - Country:US
Mailing Address - Phone:773-564-5444
Mailing Address - Fax:773-564-5445
Practice Address - Street 1:4646 N MARINE DR STE A6100
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5759
Practice Address - Country:US
Practice Address - Phone:773-564-5444
Practice Address - Fax:773-564-5445
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036069325207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036069325Medicaid