Provider Demographics
NPI:1154353720
Name:CLARK, STEVEN J (MD)
Entity type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:J
Last Name:CLARK
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2 GOOD SAMARITAN WAY
Mailing Address - Street 2:SUITE 235
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2408
Mailing Address - Country:US
Mailing Address - Phone:618-899-3980
Mailing Address - Fax:618-899-4793
Practice Address - Street 1:2 GOOD SAMARITAN WAY
Practice Address - Street 2:SUITE 235
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2408
Practice Address - Country:US
Practice Address - Phone:618-899-3980
Practice Address - Fax:618-899-4793
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2013-10-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL0360869552086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL257001700Medicaid
FL593596270OtherTAX ID NUMBER
FL257001700Medicaid
FL593596270OtherTAX ID NUMBER