Basic Information
| Provider Information | |||||||||
| NPI: | 1124120431 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KLEIN | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 265 GRIFFIN ST E | ||||||||
| Address2: | |||||||||
| City: | AMERY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540011439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152688000 | ||||||||
| FaxNumber: | 7152680311 | ||||||||
| Practice Location | |||||||||
| Address1: | 265 GRIFFIN ST E | ||||||||
| Address2: | |||||||||
| City: | AMERY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540011439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152688000 | ||||||||
| FaxNumber: | 7152680311 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2006 | ||||||||
| LastUpdateDate: | 02/18/2015 | ||||||||
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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 | 207Q00000X | 38035 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 53810 | MN | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 38035 | 01 | WI | MEDICAL LICENSE | OTHER | 32278300 | 05 | WI | MEDICAID |