Provider Demographics
NPI:1114191996
Name:KLEWIN, MARK (H,IS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:KLEWIN
Suffix:
Gender:M
Credentials:H,IS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 CORPORATE DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-1281
Mailing Address - Country:US
Mailing Address - Phone:920-887-2822
Mailing Address - Fax:920-887-9655
Practice Address - Street 1:4038 E TOWNE BLVD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-3734
Practice Address - Country:US
Practice Address - Phone:608-240-2900
Practice Address - Fax:920-887-9655
Is Sole Proprietor?:No
Enumeration Date:2008-04-14
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1293-060237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42840300Medicaid