=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659392751
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KLEIN & SLOTTEN MEDICAL ASSOCIATES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2006
-----------------------------------------------------
Last Update Date | 07/29/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 711 W NORTH AVE STE 209
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60610-1042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-280-0996
-----------------------------------------------------
Fax | 312-280-8789
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 711 W NORTH AVE STE 209
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60610-1042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-280-0996
-----------------------------------------------------
Fax | 312-280-8789
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MRS. MARY AMMONS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 312-280-0996
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QA0505X
-----------------------------------------------------
Taxonomy Name | Adult Medicine Physician
-----------------------------------------------------
License Number | 036059654
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------