Provider Demographics
NPI:1639170996
Name:KLINE, MITCHELL J
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:J
Last Name:KLINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1214 SPRING ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-3700
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1214 SPRING ST
Practice Address - Street 2:SUITE 2
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3700
Practice Address - Country:US
Practice Address - Phone:212-263-5230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01052517A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200315800Medicaid
IN121210OMedicare Oscar/Certification
INH15971Medicare UPIN
IN241630OMedicare Oscar/Certification
IN200315800Medicaid