Basic Information
Provider Information | |||||||||
NPI: | 1417960584 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KLEIN | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | A | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 26666 | ||||||||
Address2: | PHS PROVIDER ENROLLMENT | ||||||||
City: | ALBUQUERQUE | ||||||||
State: | NM | ||||||||
PostalCode: | 871256666 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5059236770 | ||||||||
FaxNumber: | 5059235354 | ||||||||
Practice Location | |||||||||
Address1: | 4005 HIGH RESORT BLVD SE | ||||||||
Address2: | PMG RIO RANCHO HIGH RESORT 4005 | ||||||||
City: | RIO RANCHO | ||||||||
State: | NM | ||||||||
PostalCode: | 871245906 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5054626000 | ||||||||
FaxNumber: | 5054628686 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/13/2006 | ||||||||
LastUpdateDate: | 03/27/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 000288 | CT | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 208000000X | A-1837-14 | NM | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
No ID Information.