Healthcare Provider Details

I. General information

NPI: 1902824378
Provider Name (Legal Business Name): RICHARD BLAKE KLINE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 02/24/2021
Certification Date: 02/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2767 CULTRA RD
CONWAY SC
29526-3716
US

IV. Provider business mailing address

2767 CULTRA RD
CONWAY SC
29526-3716
US

V. Phone/Fax

Practice location:
  • Phone: 843-438-8470
  • Fax: 843-438-8480
Mailing address:
  • Phone: 843-438-8470
  • Fax: 843-438-8480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number20364
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number20364
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: