Healthcare Provider Details

I. General information

NPI: 1083064299
Provider Name (Legal Business Name): STEVEN KLUCK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2016
Last Update Date: 07/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12935 GREGORY ST
BLUE ISLAND IL
60406-2428
US

IV. Provider business mailing address

4535 DRESSLER RD NW
CANTON OH
44718-2545
US

V. Phone/Fax

Practice location:
  • Phone: 708-597-2000
  • Fax:
Mailing address:
  • Phone: 800-828-0898
  • Fax: 330-493-8677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.005864
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: