Healthcare Provider Details

I. General information

NPI: 1871589754
Provider Name (Legal Business Name): KURT J KLISE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 SW BROOKSIDE DR
GRIMES IA
50111-4900
US

IV. Provider business mailing address

PO BOX 1475
DES MOINES IA
50305-1475
US

V. Phone/Fax

Practice location:
  • Phone: 515-300-3900
  • Fax: 515-300-3901
Mailing address:
  • Phone: 515-300-3900
  • Fax: 515-300-3901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number24439
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: