Healthcare Provider Details

I. General information

NPI: 1184604282
Provider Name (Legal Business Name): CLARK MCCLURKIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10801 S WESTERN AVE STE 201
CHICAGO IL
60643-3225
US

IV. Provider business mailing address

210 S DESPLAINES ST
CHICAGO IL
60661-5500
US

V. Phone/Fax

Practice location:
  • Phone: 773-770-4824
  • Fax:
Mailing address:
  • Phone: 312-654-2700
  • Fax: 312-654-9930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number036078948
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: