Provider Demographics
NPI:1568462687
Name:RIANS, CLARK B (MD)
Entity Type:Individual
Prefix:DR
First Name:CLARK
Middle Name:B
Last Name:RIANS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 N WILLIAM KUMPF BLVD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61605-2507
Mailing Address - Country:US
Mailing Address - Phone:309-676-5546
Mailing Address - Fax:309-647-6504
Practice Address - Street 1:303 N WILLIAM KUMPF BLVD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61605-2507
Practice Address - Country:US
Practice Address - Phone:309-676-5546
Practice Address - Fax:309-647-6504
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36067263207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36067263Medicaid
ILL15667Medicare PIN
IL36067263Medicaid