Basic Information
| Provider Information | |||||||||
| NPI: | 1134295264 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SCHANDORF | ||||||||
| FirstName: | WINSTON | ||||||||
| MiddleName: | STEPHEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 NINTH STREET NORTH | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557922398 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187413340 | ||||||||
| FaxNumber: | 2187499427 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 NINTH STREET NORTH | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557922398 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187413340 | ||||||||
| FaxNumber: | 2187499427 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 06/29/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 29830 | MN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 140280300 | 05 | MN | MEDICAID |