Provider Demographics
NPI:1386631596
Name:KLEMM, MARIANNE (DO)
Entity Type:Individual
Prefix:DR
First Name:MARIANNE
Middle Name:
Last Name:KLEMM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:#1 SOUTHROWNE DRIVE
Mailing Address - Street 2:GREAT MINES HEALTH CENTER
Mailing Address - City:POTOSI
Mailing Address - State:MO
Mailing Address - Zip Code:63664-5729
Mailing Address - Country:US
Mailing Address - Phone:573-438-9355
Mailing Address - Fax:573-438-1070
Practice Address - Street 1:1 SOUTHTOWNE DR
Practice Address - Street 2:SUITE B
Practice Address - City:POTOSI
Practice Address - State:MO
Practice Address - Zip Code:63664-5729
Practice Address - Country:US
Practice Address - Phone:573-438-9355
Practice Address - Fax:573-438-7892
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8A67207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO241300706Medicaid
MO168052OtherBCBS
MO168052OtherBCBS
MO926991810Medicare ID - Type Unspecified