Basic Information
| Provider Information | |||||||||
| NPI: | 1063468288 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KLAMERUS | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | FRANK | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 416 CONNABLE AVE | ||||||||
| Address2: | |||||||||
| City: | PETOSKEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497702212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2314877129 | ||||||||
| FaxNumber: | 2314873082 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 N OTSEGO AVE | ||||||||
| Address2: | |||||||||
| City: | GAYLORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497351558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897317760 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 11/12/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RX0202X | 4301095357 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 4301095357 | 01 | MI | STATE LICENSE | OTHER |