Provider Demographics
NPI:1659366276
Name:KLINE, RANDALL I (DPM)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:I
Last Name:KLINE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 N EDDY ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-3096
Mailing Address - Country:US
Mailing Address - Phone:574-247-4667
Mailing Address - Fax:574-271-4458
Practice Address - Street 1:211 N EDDY ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-3096
Practice Address - Country:US
Practice Address - Phone:574-247-4667
Practice Address - Fax:574-271-4458
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000940A213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN07000940AOtherLICENSE
IN200471400Medicaid
GAP00131601OtherRR MEDICARE
IN000000891332OtherANTHEM BCBS
BK7827516OtherDEA
INU93123Medicare UPIN
IN0804860001Medicare NSC
IN07000940AOtherLICENSE