Provider Demographics
NPI:1174605505
Name:CLEMENTZ, GREGORY
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:CLEMENTZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5111 N GLEN PARK PLACE RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-4675
Mailing Address - Country:US
Mailing Address - Phone:309-683-5700
Mailing Address - Fax:309-683-5752
Practice Address - Street 1:5111 N GLEN PARK PLACE RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4675
Practice Address - Country:US
Practice Address - Phone:309-683-5700
Practice Address - Fax:309-683-5752
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL080065842 / CA4079Medicare ID - Type UnspecifiedRR
IL815980Medicare ID - Type UnspecifiedGROUP #
C37678Medicare UPIN
ILL34123Medicare ID - Type UnspecifiedINDIVIDUAL #