Provider Demographics
NPI:1891809067
Name:CLARK, NINA M
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 S 1ST AVE
Mailing Address - Street 2:LOYOLA UNIVERSITY HEALTH SYSTEM FAHEY CENTER RM 112
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-3328
Mailing Address - Country:US
Mailing Address - Phone:708-216-3232
Mailing Address - Fax:708-216-8198
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:LOYOLA UNIVERSITY HEALTH SYSTEM FAHEY CENTER RM 112
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:708-216-3232
Practice Address - Fax:708-216-8198
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036108439207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
K25827Medicare ID - Type Unspecified
F97518Medicare UPIN