Healthcare Provider Details

I. General information

NPI: 1659366276
Provider Name (Legal Business Name): RANDALL I KLINE D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 03/21/2023
Certification Date: 03/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 N EDDY ST
SOUTH BEND IN
46617-3096
US

IV. Provider business mailing address

211 N EDDY ST
SOUTH BEND IN
46617-3096
US

V. Phone/Fax

Practice location:
  • Phone: 574-247-4667
  • Fax: 574-271-4458
Mailing address:
  • Phone: 574-247-4667
  • Fax: 574-271-4458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number07000940A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: