Basic Information
| Provider Information | |||||||||
| NPI: | 1851331342 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KLESCHEN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | Z | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7609 | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598077609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067215600 | ||||||||
| FaxNumber: | 4067213907 | ||||||||
| Practice Location | |||||||||
| Address1: | 2835 FORT MISSOULA RD | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598047423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067215600 | ||||||||
| FaxNumber: | 4067213907 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 10749 | MT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0147381 | 05 | MT | MEDICAID |