Provider Demographics
NPI:1609996420
Name:CLARKE, GREGORY (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:
Last Name:CLARKE
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:PO BOX 802080
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60680-2080
Mailing Address - Country:US
Mailing Address - Phone:312-236-3175
Mailing Address - Fax:312-236-3177
Practice Address - Street 1:333 N MICHIGAN AVE
Practice Address - Street 2:SUITE 2014
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-3901
Practice Address - Country:US
Practice Address - Phone:312-236-3175
Practice Address - Fax:312-263-3177
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-071641207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD16460Medicare UPIN