Basic Information
| Provider Information | |||||||||
| NPI: | 1104829688 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARKE | ||||||||
| FirstName: | STANLEY | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15055 COLLECTION CENTER DR | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606930001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563833325 | ||||||||
| FaxNumber: | 4802128451 | ||||||||
| Practice Location | |||||||||
| Address1: | 1110 S JACKSON HWY | ||||||||
| Address2: | |||||||||
| City: | SHEFFIELD | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356605747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563835211 | ||||||||
| FaxNumber: | 2563811517 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2005 | ||||||||
| LastUpdateDate: | 05/08/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 00019049 | AL | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 051504899 | 01 | AL | AL BCBS | OTHER | 051504900 | 01 | AL | AL BCBS | OTHER | 529909740 | 05 | AL | MEDICAID | 103413 | 05 | AL | MEDICAID | 515-45255 | 01 | AL | BCBS AL | OTHER | 515-45256 | 01 | AL | BCBS AL | OTHER | 103086 | 05 | AL | MEDICAID | 009973900 | 05 | AL | MEDICAID | 051550973 | 05 | AL | MEDICAID |