Healthcare Provider Details

I. General information

NPI: 1528047826
Provider Name (Legal Business Name): KENNETH D. KLEIST MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2006
Last Update Date: 12/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 S RIDGE RD
GREEN BAY WI
54304-4125
US

IV. Provider business mailing address

PO BOX 22487
GREEN BAY WI
54305-2487
US

V. Phone/Fax

Practice location:
  • Phone: 920-430-4888
  • Fax: 920-430-4889
Mailing address:
  • Phone: 920-445-7222
  • Fax: 920-445-7289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number54913-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: