MEDICARE: DR. PETER M CLARKE MD

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	207R00000X	Internal Medicine Physician	036-074696	IL

General Provider Information

NPI Number	:	1366485831
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PETER M CLARKE MD

Provider Business Mailing Address
First Line	:	1900 W POLK ST
Second Line	:	#1532
City	:	CHICAGO
State	:	IL
Zip	:	60612-3723
Country	:	US
Telephone Number	:	312-864-7234
Fax Number	:	312-864-9725

Provider Business Practice Location Address
First Line	:	1900 W POLK ST
Second Line	:	#1532
City	:	CHICAGO
State	:	IL
Zip	:	60612-3723
Country	:	US
Telephone Number	:	312-864-7234
Fax Number	:	312-864-9725

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

Provider Enumeration Date	:	06/13/2006
Last Update Date	:	04/22/2021

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