Healthcare Provider Details

I. General information

NPI: 1558304501
Provider Name (Legal Business Name): MATTHEW TODD KLEINBUB M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 06/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 WALTON WAY
AUGUSTA GA
30901-2612
US

IV. Provider business mailing address

1824 WALTON WAY
AUGUSTA GA
30904-3804
US

V. Phone/Fax

Practice location:
  • Phone: 706-737-9250
  • Fax: 706-733-0697
Mailing address:
  • Phone: 706-737-9250
  • Fax: 706-733-0697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number052976
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number052976
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: