MEDICARE: DR. ELIZABETH ELLEN KLENK MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	35.080005	OH

General Provider Information

NPI Number	:	1194042432
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELIZABETH ELLEN KLENK MD

Provider Business Mailing Address
First Line	:	269 PORTLAND WAY SOUTH
Second Line	:
City	:	GALION
State	:	OH
Zip	:	44833
Country	:	US
Telephone Number	:	419-462-4544
Fax Number	:	419-462-4566

Provider Business Practice Location Address
First Line	:	1661 VENTURE DR
Second Line	:
City	:	MOUNT VERNON
State	:	OH
Zip	:	43050-8928
Country	:	US
Telephone Number	:	740-397-2915
Fax Number	:	740-397-3870

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/27/2010
Last Update Date	:	02/22/2018

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