Provider Demographics
NPI:1588744544
Name:RUSSELL A. KLEIN, MD, A MEDICAL CORPORATION
Entity type:Organization
Organization Name:RUSSELL A. KLEIN, MD, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:A
Authorized Official - Last Name:KLEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-788-7500
Mailing Address - Street 1:16101 VENTURA BOULEVARD
Mailing Address - Street 2:SUITE 340
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436
Mailing Address - Country:US
Mailing Address - Phone:818-788-7500
Mailing Address - Fax:818-380-9245
Practice Address - Street 1:16101 VENTURA BOULEVARD
Practice Address - Street 2:SUITE 340
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436
Practice Address - Country:US
Practice Address - Phone:818-788-7500
Practice Address - Fax:818-380-9245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207RI0200X
CAG22898207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA41762Medicare UPIN
W2135Medicare PIN
A41762Medicare UPIN