1609984715 NPI number — DR. KAMERON BURKE KLOSTERMAN MD

Table of content: MRS. ALANTE J GAINES (NPI 1285326686)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609984715 NPI number — DR. KAMERON BURKE KLOSTERMAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KLOSTERMAN
Provider First Name:
KAMERON
Provider Middle Name:
BURKE
Provider Name Prefix Text:
DR.
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:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609984715
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 743070
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-3070
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-560-4304
Provider Business Mailing Address Fax Number:
864-560-4413

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7221 S PINE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PACOLET
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29372-3122
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-474-1528
Provider Business Practice Location Address Fax Number:
864-474-1049
Provider Enumeration Date:
08/28/2006

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: 207Q00000X , with the licence number:  27023 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 270236 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01221611 . This is a "RAIRLROAD MEDICARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: SC9525J577 . This is a "MEDICARE PIN" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 9997050 . This is a "AETNA" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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