Basic Information
| Provider Information | |||||||||
| NPI: | 1851365530 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KLOSS | ||||||||
| FirstName: | RAYMOND | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | N17W24100 RIVERWOOD DR | ||||||||
| Address2: | WAUKESHA HEALTH CARE INC | ||||||||
| City: | WAUKESHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531881177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2629284100 | ||||||||
| FaxNumber: | 2629285835 | ||||||||
| Practice Location | |||||||||
| Address1: | 721 AMERICAN AVE | ||||||||
| Address2: | BEHAVIORAL MEDICINE CENTER, SUITE 501 | ||||||||
| City: | WAUKESHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531885071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2629282396 | ||||||||
| FaxNumber: | 2625441213 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 33519 | WI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 31838900 | 05 | WI | MEDICAID |