Provider Demographics
NPI:1992876080
Name:KLIE, JACK H (MD)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:H
Last Name:KLIE
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 1:1 RANDALL SQ
Mailing Address - Street 2:SUITE 305
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-2709
Mailing Address - Country:US
Mailing Address - Phone:401-521-0700
Mailing Address - Fax:401-521-0906
Practice Address - Street 1:1 RANDALL SQ
Practice Address - Street 2:SUITE 305
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-2709
Practice Address - Country:US
Practice Address - Phone:401-521-0700
Practice Address - Fax:401-521-0906
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2009-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI4568207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI849OtherBLUE CROSS
RI9000849Medicaid
RI001218OtherBLUE CHIP
RI001218OtherBLUE CHIP
RI849OtherBLUE CROSS