Provider Demographics
NPI:1902850027
Name:CLARK, STEVEN G (MD)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:G
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2351 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554-3972
Mailing Address - Country:US
Mailing Address - Phone:309-353-4159
Mailing Address - Fax:309-353-4531
Practice Address - Street 1:2351 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554-3972
Practice Address - Country:US
Practice Address - Phone:309-353-4159
Practice Address - Fax:309-353-4531
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036049330207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036049330Medicaid
IL09015685OtherBLUE CROSS BLUE SHIELD
ILP00355237OtherRAIL ROAD MEDICARE
IL09015685OtherBLUE CROSS BLUE SHIELD
ILP00355237OtherRAIL ROAD MEDICARE