Provider Demographics
NPI:1588776017
Name:KLEIN, THOMAS R (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:R
Last Name:KLEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 W NORTH AVE
Mailing Address - Street 2:209
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-1174
Mailing Address - Country:US
Mailing Address - Phone:312-280-0996
Mailing Address - Fax:312-280-8789
Practice Address - Street 1:711 W NORTH AVE
Practice Address - Street 2:209
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-1174
Practice Address - Country:US
Practice Address - Phone:312-280-0996
Practice Address - Fax:312-280-8789
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036059654207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036059654Medicaid
IL539790Medicare ID - Type UnspecifiedMEDICAL GROUP NUMBER
ILD14583Medicare UPIN