Basic Information
| Provider Information | |||||||||
| NPI: | 1861543720 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KLAMATH SURGICAL ASSOCIATES PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1359 | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976010075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418821540 | ||||||||
| FaxNumber: | 5418822583 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 BRYANT WILLIAMS DR | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976011120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418833391 | ||||||||
| FaxNumber: | 5418832250 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2007 | ||||||||
| LastUpdateDate: | 11/02/2007 | ||||||||
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| AuthorizedOfficialLastName: | MCCLURE | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | THOMAS | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5418833391 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD11222 | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | CN5695 | 01 | RAILROAD MEDICARE | OTHER | 006213 | 05 | OR | MEDICAID |