Provider Demographics
NPI:1487772208
Name:STEPHEN J. CLARK M.D.,P.C.
Entity type:Organization
Organization Name:STEPHEN J. CLARK M.D.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-356-9300
Mailing Address - Street 1:3021 FALLING WATERS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LINDENHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60046-6793
Mailing Address - Country:US
Mailing Address - Phone:847-356-9300
Mailing Address - Fax:847-356-7260
Practice Address - Street 1:3021 FALLING WATERS BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:LINDENHURST
Practice Address - State:IL
Practice Address - Zip Code:60046-6793
Practice Address - Country:US
Practice Address - Phone:847-356-9300
Practice Address - Fax:847-356-7260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL625120Medicare ID - Type Unspecified