1376500447 NPI number — KELLY KLEIN MD

Table of content: KELLY KLEIN MD (NPI 1376500447)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376500447 NPI number — KELLY KLEIN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KLEIN
Provider First Name:
KELLY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KLEIN
Provider Other First Name:
KELLY
Provider Other Middle Name:
LOCKWOOD
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1376500447
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5865
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUBBOCK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79408-5865
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-743-2898
Provider Business Mailing Address Fax Number:
806-743-2787

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3601 4TH ST
Provider Second Line Business Practice Location Address:
MS 8143
Provider Business Practice Location Address City Name:
LUBBOCK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79430-0002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-743-2757
Provider Business Practice Location Address Fax Number:
806-743-2563
Provider Enumeration Date:
05/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207QH0002X , with the licence number:  K1226 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: K1226 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8J9140 . This is a "BCBS LHC" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0001KH . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 100192101 . This is a "FIRSTCARE LHC" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 162693901 . This is a "LHC MEDICAID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 130893408 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100192105 . This is a "FIRSTCARE INDIVIDUAL" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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