MEDICARE: MARK JACOB KLEINMAN PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	010039	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164445771
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK JACOB KLEINMAN PH.D.

Provider Business Mailing Address
First Line	:	144 NEHRING AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-6120
Country	:	US
Telephone Number	:	917-595-7520
Fax Number	:

Provider Business Practice Location Address
First Line	:	3915 HYLAN BLVD
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10308-3425
Country	:	US
Telephone Number	:	718-948-7800
Fax Number	:	718-948-1733

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	07/08/2007

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