MEDICARE: STANLEY D CLARKE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0001X	Radiation Oncology Physician	00019049	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	051504899	OTHER	AL	AL BCBS
2	051504900	OTHER	AL	AL BCBS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	515-45255	OTHER	AL	BCBS AL
6	515-45256	OTHER	AL	BCBS AL
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
9	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104829688
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STANLEY D CLARKE M.D.

Provider Business Mailing Address
First Line	:	15055 COLLECTION CENTER DR
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60693-0001
Country	:	US
Telephone Number	:	256-383-3325
Fax Number	:	480-212-8451

Provider Business Practice Location Address
First Line	:	1110 S JACKSON HWY
Second Line	:
City	:	SHEFFIELD
State	:	AL
Zip	:	35660-5747
Country	:	US
Telephone Number	:	256-383-5211
Fax Number	:	256-381-1517

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	05/08/2012

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Directions to “ STANLEY D CLARKE M.D.” Practice Location

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