Basic Information
| Provider Information | |||||||||
| NPI: | 1659366276 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KLINE | ||||||||
| FirstName: | RANDALL | ||||||||
| MiddleName: | I | ||||||||
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| Credential: | D.P.M. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6301 UNIVERSITY COMMONS | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466351571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742474667 | ||||||||
| FaxNumber: | 5742714458 | ||||||||
| Practice Location | |||||||||
| Address1: | 6301 UNIVERSITY COMMONS | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466351571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742474667 | ||||||||
| FaxNumber: | 5742714458 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2005 | ||||||||
| LastUpdateDate: | 12/03/2014 | ||||||||
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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 | 213ES0103X | 07000940A | IN | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 000000891332 | 01 | IN | ANTHEM BCBS | OTHER | 07000940A | 01 | IN | LICENSE | OTHER | 200471400 | 05 | IN | MEDICAID | P00131601 | 01 | GA | RR MEDICARE | OTHER | BK7827516 | 01 | DEA | OTHER |