Provider Demographics
NPI:1740272483
Name:CLEMIS, JACK D (MD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:D
Last Name:CLEMIS
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 1:151 N MICHIGAN AVE
Mailing Address - Street 2:#914
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-7506
Mailing Address - Country:US
Mailing Address - Phone:312-938-4327
Mailing Address - Fax:312-938-0490
Practice Address - Street 1:151 N MICHIGAN AVE
Practice Address - Street 2:#914
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-7506
Practice Address - Country:US
Practice Address - Phone:312-938-4327
Practice Address - Fax:312-938-0490
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2013-02-13
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
IL036-038421207YX0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & Neurotology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1604366OtherBLUE CROSS
IL1604366OtherBLUE CROSS
K37444Medicare PIN