Provider Demographics
NPI:1013049808
Name:KLOBAS, RUSSELL ALBERT (LIC AC)
Entity type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:ALBERT
Last Name:KLOBAS
Suffix:
Gender:M
Credentials:LIC AC
Other - Prefix:
Other - First Name:RUSTY
Other - Middle Name:ALBERT
Other - Last Name:KLOBAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MAC
Mailing Address - Street 1:228 WATER ST
Mailing Address - Street 2:
Mailing Address - City:HALLOWELL
Mailing Address - State:ME
Mailing Address - Zip Code:04347-1335
Mailing Address - Country:US
Mailing Address - Phone:207-621-0985
Mailing Address - Fax:207-621-0985
Practice Address - Street 1:228 WATER ST
Practice Address - Street 2:
Practice Address - City:HALLOWELL
Practice Address - State:ME
Practice Address - Zip Code:04347-1335
Practice Address - Country:US
Practice Address - Phone:207-621-0985
Practice Address - Fax:207-621-0985
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAC105171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME022750OtherANTHEM BCBS PIN NUMBER