MEDICARE: DR. JOHN EDGAR KLECKLEY M.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	207RG0300X	Geriatric Medicine (Internal Medicine) Physician	29749	SC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00467100	OTHER	SC	RAILROAD MEDICARE PIN
3	P00803393	OTHER	SC	RAILROAD MEDICARE ID-RSFPN

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	:	1356544100
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN EDGAR KLECKLEY M.D.

Provider Business Mailing Address
First Line	:	PO BOX 530062
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30353-0062
Country	:	US
Telephone Number	:	436-956-0718
Fax Number	:	843-569-5879

Provider Business Practice Location Address
First Line	:	3710 LANDMARK DR STE 408
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29204-4034
Country	:	US
Telephone Number	:	803-799-1922
Fax Number	:

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

Provider Enumeration Date	:	06/08/2007
Last Update Date	:	11/22/2024

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