Provider Demographics
NPI:1770541369
Name:CLEM, ANDREA SUE (DO)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:SUE
Last Name:CLEM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5404 W ELM ST
Mailing Address - Street 2:SUITE Q
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-4052
Mailing Address - Country:US
Mailing Address - Phone:815-344-0020
Mailing Address - Fax:815-344-0076
Practice Address - Street 1:5404 W ELM ST
Practice Address - Street 2:SUITE Q
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-4052
Practice Address - Country:US
Practice Address - Phone:815-344-0020
Practice Address - Fax:815-344-0076
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2010-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34007131C207Q00000X
IL036123085207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2184372Medicaid
000000201819OtherANTHEM
H16982Medicare UPIN
CL4022532Medicare ID - Type Unspecified