Basic Information
| Provider Information | |||||||||
| NPI: | 1841208782 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KLIMOVA | ||||||||
| FirstName: | IRINA | ||||||||
| MiddleName: | VIKTOROVNA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KVATADZE | ||||||||
| OtherFirstName: | IRINA | ||||||||
| OtherMiddleName: | VIKTOROVNA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 131158 | ||||||||
| Address2: | ANN ARBOR INPT PHYSICIANS | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481131158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347370970 | ||||||||
| FaxNumber: | 7347370974 | ||||||||
| Practice Location | |||||||||
| Address1: | 5301 E HURON RIVER DR | ||||||||
| Address2: | ST JOSEPH MERCY HOSPITAL | ||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347123456 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301079903 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.