=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235248857
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN WILLIAM KLEMME M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2006
-----------------------------------------------------
Last Update Date | 08/06/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9330 BROADWAY
-----------------------------------------------------
City | CROWN POINT
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46307-8602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-644-1243
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12144 NORTHCOTE CT
-----------------------------------------------------
City | SAINT JOHN
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46373-9541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-365-4298
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | 01027097A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------