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General NPI Number Information
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NPI Number | 1609996420
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Entity Type | Individual
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Provider Name | GREGORY CLARKE M.D.
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Gender | Male
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Dates
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Enumeration Date | 03/29/2007
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Last Update Date | 04/26/2010
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Provider Practice Location Address
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Address Line | 333 N MICHIGAN AVE SUITE 2014
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City | CHICAGO
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State | IL
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Zip | 60601-3901
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Country | US
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Telephone | 312-236-3175
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Fax | 312-263-3177
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Provider Business Mailing Address
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Address Line | PO BOX 802080
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City | CHICAGO
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State | IL
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Zip | 60680-2080
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Country | US
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Telephone | 312-236-3175
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Fax | 312-236-3177
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 036-071641
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License Number State | IL
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