Healthcare Provider Details

I. General information

NPI: 1033372727
Provider Name (Legal Business Name): ROBERT EDWARD CLARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2008
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1709 TULLAMORE AVE STE C
BLOOMINGTON IL
61704-9603
US

IV. Provider business mailing address

1709 TULLAMORE AVE STE C
BLOOMINGTON IL
61704-9603
US

V. Phone/Fax

Practice location:
  • Phone: 309-454-5900
  • Fax: 309-454-2820
Mailing address:
  • Phone: 309-454-5900
  • Fax: 309-454-2820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number036131371
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMT190170
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number2010017443
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: