Basic Information
| Provider Information | |||||||||
| NPI: | 1861757874 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLEMENT S ROSE MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1210 | ||||||||
| Address2: | |||||||||
| City: | MATTESON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604434210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7089577623 | ||||||||
| FaxNumber: | 7087202035 | ||||||||
| Practice Location | |||||||||
| Address1: | 4646 N MARINE DR | ||||||||
| Address2: | SUITE A5800 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606405759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7735645444 | ||||||||
| FaxNumber: | 7735645445 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2012 | ||||||||
| LastUpdateDate: | 07/06/2012 | ||||||||
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| AuthorizedOfficialLastName: | ROSE | ||||||||
| AuthorizedOfficialFirstName: | CLEMENT | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7735645363 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.