Basic Information
| Provider Information | |||||||||
| NPI: | 1942564802 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KLECKA | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26908 DETROIT RD | ||||||||
| Address2: | STE. 301 | ||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441452398 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408926406 | ||||||||
| FaxNumber: | 4406170884 | ||||||||
| Practice Location | |||||||||
| Address1: | 26908 DETROIT RD | ||||||||
| Address2: | STE. 200 | ||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441452398 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402508660 | ||||||||
| FaxNumber: | 4402508639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2012 | ||||||||
| LastUpdateDate: | 11/01/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 56604 | MN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 35.127125 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0152379 | 05 | OH | MEDICAID |