Basic Information
| Provider Information | |||||||||
| NPI: | 1255427779 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLEMENTS | ||||||||
| FirstName: | DEBORAH | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCPHERSON | ||||||||
| OtherFirstName: | DEBORAH | ||||||||
| OtherMiddleName: | S | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 710 N LAKE SHORE DR | ||||||||
| Address2: | ABBOTT HALL, 4TH FLOOR | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606113006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3125031275 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1275 E BELVIDERE RD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | GRAYSLAKE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600302082 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479260106 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 05/22/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 04-28569 | KS | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200003340B | 05 | KS | MEDICAID | 26402044 | 01 | MO | BCBS KANSAS CITY | OTHER | 373060 | 01 | KS | FIRSTGUARD | OTHER | 209401900 | 05 | MO | MEDICAID |