Basic Information
| Provider Information | |||||||||
| NPI: | 1063702876 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KLEM | ||||||||
| FirstName: | THEODORE | ||||||||
| MiddleName: | CARROLL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 844658 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752844658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2547242111 | ||||||||
| FaxNumber: | 2547247603 | ||||||||
| Practice Location | |||||||||
| Address1: | 35 MEDICAL CENTER PKWY | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | ME | ||||||||
| PostalCode: | 043308160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076261000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2011 | ||||||||
| LastUpdateDate: | 10/18/2019 | ||||||||
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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 | 207R00000X | Q0485 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | BP10039985 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MD23168 | ME | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 375277YLP2 | 01 | TX | MEDICARE PTAN | OTHER | 375277YKXV | 01 | TX | MEDICARE PTAN | OTHER | 375277YLP1 | 01 | TX | MEDICARE PTAN | OTHER | 375277YKXY | 01 | TX | MEDICARE PTAN | OTHER |