Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QG0300X | Family Doctor - Geriatric Medicine | TL29749 | SC |
NPI | 1356544100 |
---|---|
Provider Name | Dr. John Edgar Kleckley |
First Address | Sumter, SC 29150-4256 |
Second Address | Sumter, SC 29150-4256 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/06/2007 |
Last Update Date | 18/06/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
297495 | (05) | SC |
P00467100 | RAILROAD MEDICARE PIN (01) | SC |
P00803393 | RAILROAD MEDICARE ID-RSFPN (01) | SC |