Basic Information
| Provider Information | |||||||||
| NPI: | 1376500447 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KLEIN | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KLEIN | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | LOCKWOOD | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 5865 | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794085865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067432898 | ||||||||
| FaxNumber: | 8067432787 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 4TH ST | ||||||||
| Address2: | MS 8143 | ||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794300002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067432757 | ||||||||
| FaxNumber: | 8067432563 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2006 | ||||||||
| LastUpdateDate: | 12/02/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QH0002X | K1226 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine | Hospice and Palliative Medicine | 207Q00000X | K1226 | TX | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8J9140 | 01 | TX | BCBS LHC | OTHER | 0001KH | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 100192101 | 01 | TX | FIRSTCARE LHC | OTHER | 162693901 | 01 | TX | LHC MEDICAID | OTHER | 130893408 | 05 | TX | MEDICAID | 100192105 | 01 | TX | FIRSTCARE INDIVIDUAL | OTHER |