Basic Information
| Provider Information | |||||||||
| NPI: | 1538693676 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KLONIECKE | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1025 WALNUT ST STE 1100 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191075001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159551416 | ||||||||
| FaxNumber: | 2159231884 | ||||||||
| Practice Location | |||||||||
| Address1: | 833 CHESTNUT ST STE 703 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159551000 | ||||||||
| FaxNumber: | 2155032066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2017 | ||||||||
| LastUpdateDate: | 06/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | MT214398 | PA | Y | Allopathic & Osteopathic Physicians | Urology |
No ID Information.