MEDICARE: MR. WILLIAM A CLARK PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT001501E	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	50004079	OTHER	PA	CAPITAL BLUE CROSS
2	CL551250	OTHER	PA	BLUE SHEILD

General Provider Information

NPI Number	:	1205837747
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WILLIAM A CLARK PT

Provider Business Mailing Address
First Line	:	2001 BUTTERFIELD RD STE 1600
Second Line	:
City	:	DOWNERS GROVE
State	:	IL
Zip	:	60515-1211
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4304 5TH STREET HWY UNIT 4
Second Line	:
City	:	TEMPLE
State	:	PA
Zip	:	19560-1740
Country	:	US
Telephone Number	:	484-220-2912
Fax Number	:	610-929-2472

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	04/16/2025

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