Basic Information
| Provider Information | |||||||||
| NPI: | 1376628529 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KLEIN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | N. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 102 RIVERVIEW DR STE A | ||||||||
| Address2: | |||||||||
| City: | FLOWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392328908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019811610 | ||||||||
| FaxNumber: | 6013662887 | ||||||||
| Practice Location | |||||||||
| Address1: | 102 RIVERVIEW DR STE A | ||||||||
| Address2: | |||||||||
| City: | FLOWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392328908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019811610 | ||||||||
| FaxNumber: | 6013662887 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 04/27/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 04/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 15985 | MS | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 00125529 | 05 | MS | MEDICAID |