Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 036129725 | IL |
N | 207QS0010X | Family Doctor - Sports Medicine | 036129725 | IL |
NPI | 1144457169 |
---|---|
Provider Name | Brian Klostermann |
First Address | Chicago, IL 60686-0001 |
Second Address | Highland, IL 62249-2898 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/06/2009 |
Last Update Date | 22/12/2021 |