Provider Demographics
NPI:1487646535
Name:CLARK, ELIZABETH TALLEY (MD, RVT)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:TALLEY
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD, RVT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1614 W CENTRAL RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-2490
Mailing Address - Country:US
Mailing Address - Phone:847-577-5814
Mailing Address - Fax:847-577-5914
Practice Address - Street 1:1614 W CENTRAL RD
Practice Address - Street 2:SUITE 100
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-2490
Practice Address - Country:US
Practice Address - Phone:847-577-5814
Practice Address - Fax:847-577-5914
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0769272086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1487646535OtherNPI
IL036-076927-1Medicaid
K08773Medicare PIN
IL357801Medicare PIN
IL1487646535OtherNPI
E18362Medicare UPIN
K08773Medicare Oscar/Certification
ILE18362Medicare UPIN