Healthcare Provider Details

I. General information

NPI: 1740272483
Provider Name (Legal Business Name): JACK D CLEMIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 02/13/2013
Certification Date:
Deactivation Date: 03/21/2006
Reactivation Date: 04/05/2006

III. Provider practice location address

151 N MICHIGAN AVE #914
CHICAGO IL
60601-7506
US

IV. Provider business mailing address

151 N MICHIGAN AVE #914
CHICAGO IL
60601-7506
US

V. Phone/Fax

Practice location:
  • Phone: 312-938-4327
  • Fax: 312-938-0490
Mailing address:
  • Phone: 312-938-4327
  • Fax: 312-938-0490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License Number036-038421
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: