Basic Information
| Provider Information | |||||||||
| NPI: | 1497776363 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KLC SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4555 W SCHROEDER DR | ||||||||
| Address2: | SUITE #170 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532231475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143653210 | ||||||||
| FaxNumber: | 4143653225 | ||||||||
| Practice Location | |||||||||
| Address1: | 7007 N RANGE LINE RD | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532092620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143523341 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2006 | ||||||||
| LastUpdateDate: | 03/31/2008 | ||||||||
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| AuthorizedOfficialLastName: | KANITZ | ||||||||
| AuthorizedOfficialFirstName: | KRISTI | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4143523341 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 31827300 | 05 | WI | MEDICAID |