Healthcare Provider Details

I. General information

NPI: 1073883203
Provider Name (Legal Business Name): CLYDE WHITING M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2012
Last Update Date: 01/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 S CALIFORNIA AVE
CHICAGO IL
60608-1732
US

IV. Provider business mailing address

8336 S HERMITAGE AVE
CHICAGO IL
60620-4629
US

V. Phone/Fax

Practice location:
  • Phone: 773-257-6097
  • Fax:
Mailing address:
  • Phone: 312-933-6075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number036129320
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: