Basic Information
| Provider Information | |||||||||
| NPI: | 1073504767 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | TODD | ||||||||
| MiddleName: | |||||||||
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| Credential: | MEDICAL DOCTOR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29373 NETWORK PL | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606731143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473905900 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1775 W DEMPSTER ST | ||||||||
| Address2: | 1 WEST | ||||||||
| City: | PARK RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600681143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8477235150 | ||||||||
| FaxNumber: | 8477232083 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2005 | ||||||||
| LastUpdateDate: | 09/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | A84896 | CA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207PE0004X | A84896 | CA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207PE0004X | 036-107180 | IL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207P00000X | 036-107180 | IL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A84896 | 05 | CA | MEDICAID | 00A848960 | 05 | CA | MEDICAID |