Provider Demographics
NPI:1851434658
Name:JACK D. CLEMIS, MD SC
Entity type:Organization
Organization Name:JACK D. CLEMIS, MD SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:D
Authorized Official - Last Name:CLEMIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-938-4327
Mailing Address - Street 1:151 N MICHIGAN AVE
Mailing Address - Street 2:SUITE 914
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-7506
Mailing Address - Country:US
Mailing Address - Phone:312-938-4327
Mailing Address - Fax:312-938-0490
Practice Address - Street 1:151 N MICHIGAN AVE
Practice Address - Street 2:SUITE 914
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-7506
Practice Address - Country:US
Practice Address - Phone:312-938-4327
Practice Address - Fax:312-938-0490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036038421174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL422580Medicare ID - Type UnspecifiedMEDICARE
ILC40343Medicare UPIN