Provider Demographics
NPI:1881903789
Name:GREGORY CLARKE M.D., S.C.
Entity type:Organization
Organization Name:GREGORY CLARKE M.D., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-236-3175
Mailing Address - Street 1:PO BOX 802080
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60680-2080
Mailing Address - Country:US
Mailing Address - Phone:312-236-3175
Mailing Address - Fax:312-236-3177
Practice Address - Street 1:333 N MICHIGAN AVE
Practice Address - Street 2:SUITE 2014
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-3901
Practice Address - Country:US
Practice Address - Phone:312-236-3175
Practice Address - Fax:312-236-3177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-27
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-071641261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD16460Medicare UPIN