Basic Information
| Provider Information | |||||||||
| NPI: | 1366855298 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KLINE | ||||||||
| FirstName: | GEOFFREY | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9700 PETERSBURG RD | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477251458 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5145 N CALIFORNIA AVE | ||||||||
| Address2: | ATTN: GME OFFICE | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606253661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7739893808 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2014 | ||||||||
| LastUpdateDate: | 06/09/2014 | ||||||||
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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 | 213E00000X | 00400 | KY | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213E00000X | SC006420 | PA | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.