Provider Demographics
NPI:1659338010
Name:KLEIN, KELLY RUTHANNE (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:RUTHANNE
Last Name:KLEIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:489 STATE ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-6616
Mailing Address - Country:US
Mailing Address - Phone:207-973-5000
Mailing Address - Fax:207-973-5042
Practice Address - Street 1:489 STATE ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6616
Practice Address - Country:US
Practice Address - Phone:207-973-4011
Practice Address - Fax:207-973-4832
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM1839207PE0004X
ME018725207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX176249401Medicaid
TX176249401Medicaid
H96027Medicare UPIN