Provider Demographics
NPI:1780647362
Name:WHITEHOUSE, CLIFFORD C (MMS, ATC, PA-C)
Entity Type:Individual
Prefix:MR
First Name:CLIFFORD
Middle Name:C
Last Name:WHITEHOUSE
Suffix:
Gender:M
Credentials:MMS, ATC, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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Mailing Address - Street 1:7447 W TALCOTT AVE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-3745
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7447 W TALCOTT AVE
Practice Address - Street 2:SUITE 500
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-3745
Practice Address - Country:US
Practice Address - Phone:773-850-3050
Practice Address - Fax:773-631-3005
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096-0020762255A2300X
IL085004982363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1780647362OtherNPI