Basic Information
| Provider Information | |||||||||
| NPI: | 1952379570 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KLEINER | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2025 GALISTEO ST | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875052101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059954901 | ||||||||
| FaxNumber: | 5059896426 | ||||||||
| Practice Location | |||||||||
| Address1: | 2025 GALISTEO ST | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875052101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059954901 | ||||||||
| FaxNumber: | 5059896426 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 11/08/2011 | ||||||||
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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 | 208000000X | 76-209 | NM | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 00015297 | 05 | NM | MEDICAID | 10008298 | 01 | LOVELACE | OTHER | 5064209 | 01 | CCN | OTHER | PROVP13467 | 01 | MOLINA | OTHER | 1699559 | 01 | UHC | OTHER | 201005308 | 01 | PRESBYTERIAN HEALTH PLANS | OTHER | NM001515 | 01 | NM | BCBS NM | OTHER |