Provider Demographics
NPI:1174588164
Name:KLIM, JOHN A (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:KLIM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 5TH AVENUE SOUTH
Mailing Address - Street 2:
Mailing Address - City:ESCANABA
Mailing Address - State:MI
Mailing Address - Zip Code:49829
Mailing Address - Country:US
Mailing Address - Phone:906-786-6047
Mailing Address - Fax:906-786-0660
Practice Address - Street 1:2525 5TH AVENUE SOUTH
Practice Address - Street 2:
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829
Practice Address - Country:US
Practice Address - Phone:906-786-6047
Practice Address - Fax:906-786-0660
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301008917207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1752100025OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI3292357Medicaid
MICG4010OtherRAILROAD GROUP
MI3257385Medicaid
MI040013546Medicare PIN
MICG4010OtherRAILROAD GROUP
0M25870001Medicare PIN