Healthcare Provider Details

I. General information

NPI: 1962182154
Provider Name (Legal Business Name): CLIFTON SHAVAR STEWART RSA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2023
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11560 S KEDZIE AVE
MERRIONETTE PARK IL
60803-4517
US

IV. Provider business mailing address

11560 S KEDZIE AVE
MERRIONETTE PARK IL
60803-4517
US

V. Phone/Fax

Practice location:
  • Phone: 708-914-5800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: