Healthcare Provider Details

I. General information

NPI: 1659392751
Provider Name (Legal Business Name): KLEIN & SLOTTEN MEDICAL ASSOCIATES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 07/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 W NORTH AVE STE 209
CHICAGO IL
60610-1042
US

IV. Provider business mailing address

711 W NORTH AVE STE 209
CHICAGO IL
60610-1042
US

V. Phone/Fax

Practice location:
  • Phone: 312-280-0996
  • Fax: 312-280-8789
Mailing address:
  • Phone: 312-280-0996
  • Fax: 312-280-8789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number036059654
License Number StateIL

VIII. Authorized Official

Name: MRS. MARY AMMONS
Title or Position: MANAGER
Credential:
Phone: 312-280-0996