Provider Demographics
NPI:1295780153
Name:MURRAY-CLARK, MICHELLE RENEE (DPM)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:RENEE
Last Name:MURRAY-CLARK
Suffix:
Gender:F
Credentials:DPM
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 917
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60065-0917
Mailing Address - Country:US
Mailing Address - Phone:847-504-5000
Mailing Address - Fax:847-504-5015
Practice Address - Street 1:40 SKOKIE BLVD STE 520
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-1601
Practice Address - Country:US
Practice Address - Phone:847-504-5000
Practice Address - Fax:847-504-5015
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1957213E00000X
MO2011018233213E00000X
IL016-005209213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX320181602Medicaid
TX320181601Medicaid
TX320181603Medicaid
IL016005209Medicaid
MO1295780153Medicaid
0732240001OtherDMERC # WITH PPG
TX320181602Medicaid
MO149630008Medicare PIN
U82239Medicare UPIN
IL016005209Medicaid
MO149620005Medicare PIN
MO1295780153Medicaid
TX278403YPT7Medicare PIN
TX320181603Medicaid
TX278403YPREMedicare PIN