Basic Information
| Provider Information | |||||||||
| NPI: | 1114912086 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KLEIN | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | ALLAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 535 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | OLEAN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147601513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7163720141 | ||||||||
| FaxNumber: | 7163762430 | ||||||||
| Practice Location | |||||||||
| Address1: | 535 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | OLEAN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147601513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7163720141 | ||||||||
| FaxNumber: | 7163762430 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2005 | ||||||||
| LastUpdateDate: | 02/25/2009 | ||||||||
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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 | 207V00000X | 147483 | NY | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 00706634 | 05 | NY | MEDICAID |