Provider Demographics
NPI:1922380344
Name:KLEINSCHMIDT, RICHARD (PA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:KLEINSCHMIDT
Suffix:
Gender:M
Credentials:PA
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Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1000 ELEVEN SOUTH
Mailing Address - Street 2:STE 4F
Mailing Address - City:COLUMBIA
Mailing Address - State:IL
Mailing Address - Zip Code:62236
Mailing Address - Country:US
Mailing Address - Phone:618-628-0715
Mailing Address - Fax:888-371-4468
Practice Address - Street 1:2319 OLD PLANK RD
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:IL
Practice Address - Zip Code:62233-1153
Practice Address - Country:US
Practice Address - Phone:618-826-2388
Practice Address - Fax:618-826-3350
Is Sole Proprietor?:No
Enumeration Date:2011-09-12
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004123363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214881Medicare Oscar/Certification