=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346238177
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CLEMENT S ROSE M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2005
-----------------------------------------------------
Last Update Date | 12/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5025 N PAULINA ST STE 501
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640-2772
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-599-4363
-----------------------------------------------------
Fax | 773-599-4788
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5025 N PAULINA ST STE 501
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640-2772
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-599-4363
-----------------------------------------------------
Fax | 773-599-4788
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 036069325
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------