Provider Demographics
NPI:1558304501
Name:KLEINBUB, MATTHEW TODD (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:TODD
Last Name:KLEINBUB
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 1:1824 WALTON WAY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-3804
Mailing Address - Country:US
Mailing Address - Phone:706-737-9250
Mailing Address - Fax:706-733-0697
Practice Address - Street 1:1350 WALTON WAY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2612
Practice Address - Country:US
Practice Address - Phone:706-737-9250
Practice Address - Fax:706-733-0697
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052976207LP2900X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA654090702AMedicaid
SCG52976Medicaid
GAP00111540OtherRAILROAD MEDICARE
GA05BDJXKMedicare PIN
GAP00111540OtherRAILROAD MEDICARE